Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT007043 | GA |
N | 2251P0200X | Physical Therapist - Pediatrics | PT007043 | GA |
N | 2251S0007X | Physical Therapist - Sports | PT007043 | GA |
N | 2251X0800X | Physical Therapist - Orthopedic | PT007043 | GA |
NPI | 1053381400 |
---|---|
Provider Name | Teresa Bristol |
First Address | Atlanta, GA 30308-3536 |
Second Address | Atlanta, GA 30309 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/01/2006 |
Last Update Date | 20/09/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
003190988A | (05) | GA |
05207111 | AMERIGROUP (01) | GA |
105338140-001 | TRICARE SOUTH (01) | GA |
4620664 | CIGNA (01) | |
Q23752 | (02) | GA |