Provider Demographics
NPI:1891203063
Name:GUDBERGSDOTTIR, ALEXANDRA MJOLL (ATC)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:MJOLL
Last Name:GUDBERGSDOTTIR
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2158 CUMBERLAND PKWY SE APT 13408
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-4589
Mailing Address - Country:US
Mailing Address - Phone:678-862-3658
Mailing Address - Fax:
Practice Address - Street 1:405 PHARR RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-3200
Practice Address - Country:US
Practice Address - Phone:404-231-1872
Practice Address - Fax:404-231-3346
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20000299592255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer