Provider Demographics
NPI:1295043206
Name:NOURBAKHSH, MOHAMMAD REZA (DPT)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:REZA
Last Name:NOURBAKHSH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 SUNSET DR. STE 102
Mailing Address - Street 2:
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30597-0000
Mailing Address - Country:US
Mailing Address - Phone:706-482-2268
Mailing Address - Fax:706-482-2294
Practice Address - Street 1:159 SUNSET DRIVE STE 102
Practice Address - Street 2:
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30597-0000
Practice Address - Country:US
Practice Address - Phone:706-482-2268
Practice Address - Fax:706-482-2294
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT7497225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist