Provider Demographics
NPI:1124575626
Name:WAGES, KIRSTEN BROOKE (PTA)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:BROOKE
Last Name:WAGES
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6397 LEE HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2564
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-362-8684
Practice Address - Street 1:9420 WILLEO RD STE 202
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-6773
Practice Address - Country:US
Practice Address - Phone:770-594-7250
Practice Address - Fax:770-594-7251
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA003671225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant