Provider Demographics
NPI:1275015083
Name:SELLERS, MARISSA (PT)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:SELLERS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:
Other - Last Name:GACEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2463 HAMILTON MILL PKWY STE 250
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-4647
Practice Address - Country:US
Practice Address - Phone:770-932-9521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH10662225100000X
GAPT013605225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist