1811437015 NPI number — TRACEY DENIECE PASCHAL PT, DPT

Table of content: TRACEY DENIECE PASCHAL PT, DPT (NPI 1811437015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811437015 NPI number — TRACEY DENIECE PASCHAL PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PASCHAL
Provider First Name:
TRACEY
Provider Middle Name:
DENIECE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811437015
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1755 HIGHWAY 34 E
Provider Second Line Business Mailing Address:
STE 1300
Provider Business Mailing Address City Name:
NEWNAN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30265-3186
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-502-2175
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3645 MARKETPLACE BLVD
Provider Second Line Business Practice Location Address:
STE 160
Provider Business Practice Location Address City Name:
EAST POINT
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30344-5747
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-344-2823
Provider Business Practice Location Address Fax Number:
404-629-3737
Provider Enumeration Date:
03/07/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT011196 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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