Provider Demographics
NPI:1245586908
Name:CRAIN, MICHELLE MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:CRAIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 PEACHTREE RD NE STE D-203
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30319-3020
Mailing Address - Country:US
Mailing Address - Phone:323-804-1625
Mailing Address - Fax:
Practice Address - Street 1:550 PEACHTREE ST NE STE 1020
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2210
Practice Address - Country:US
Practice Address - Phone:404-874-3467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002981225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant