Provider Demographics
NPI:1467668087
Name:ALTIDOR, MARIE SHERWINE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:SHERWINE
Last Name:ALTIDOR
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 1:237 HICKORY BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-8773
Mailing Address - Country:US
Mailing Address - Phone:678-574-9071
Mailing Address - Fax:
Practice Address - Street 1:6849 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:BLDG B-1 SUITE 102
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-1610
Practice Address - Country:US
Practice Address - Phone:866-587-9922
Practice Address - Fax:678-587-9993
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002226225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPTA002226OtherPHYSICAL THERAPIST ASSIST