Provider Demographics
NPI:1396209110
Name:MCDANIEL, AUBIE BLAKE (PTA)
Entity Type:Individual
Prefix:
First Name:AUBIE
Middle Name:BLAKE
Last Name:MCDANIEL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 LUMPKIN CAMPGROUND RD S
Mailing Address - Street 2:
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-7159
Mailing Address - Country:US
Mailing Address - Phone:706-531-4769
Mailing Address - Fax:
Practice Address - Street 1:5610 HAMPTON PARK DR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-4004
Practice Address - Country:US
Practice Address - Phone:678-965-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA004049225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant