Provider Demographics
NPI:1013022417
Name:MAYNE, SUSAN HARBISON (PT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:HARBISON
Last Name:MAYNE
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 1:310 TECHNOLOGY PKWY
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-2932
Mailing Address - Country:US
Mailing Address - Phone:770-441-1580
Mailing Address - Fax:
Practice Address - Street 1:2217 ROSWELL RD.
Practice Address - Street 2:SUITE A100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062
Practice Address - Country:US
Practice Address - Phone:770-321-6600
Practice Address - Fax:770-321-5559
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT002955225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist