Provider Demographics
NPI:1477007821
Name:WEIR, MARY (PTA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WEIR
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:
Other - Last Name:WEIR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:2747 KNELSTON OAK WAY
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-7299
Mailing Address - Country:US
Mailing Address - Phone:678-642-3271
Mailing Address - Fax:
Practice Address - Street 1:3750 PEACHTREE RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30319-1322
Practice Address - Country:US
Practice Address - Phone:404-365-3163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-14
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA0001158225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant