Provider Demographics
NPI:1336554955
Name:BEAVERS, WILLIE DAVID III (PT, DPT, GCS)
Entity type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:DAVID
Last Name:BEAVERS
Suffix:III
Gender:M
Credentials:PT, DPT, GCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:549 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6347
Mailing Address - Country:US
Mailing Address - Phone:404-438-7445
Mailing Address - Fax:
Practice Address - Street 1:549 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6347
Practice Address - Country:US
Practice Address - Phone:404-438-7445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT011076225100000X, 2251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist