Provider Demographics
NPI:1861794091
Name:MCGANN, KHADIJAH LATEEF (PT)
Entity type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:LATEEF
Last Name:MCGANN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 SPRING HILL RUN
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-7023
Mailing Address - Country:US
Mailing Address - Phone:404-903-1130
Mailing Address - Fax:
Practice Address - Street 1:7245 ROCKBRIDGE RD
Practice Address - Street 2:SUITE 400
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-8613
Practice Address - Country:US
Practice Address - Phone:404-903-1130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-19
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008894225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist