Provider Demographics
NPI:1518080977
Name:EVANS, KEITH E (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:E
Last Name:EVANS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 NICKAJACK RD
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-1707
Mailing Address - Country:US
Mailing Address - Phone:770-948-8803
Mailing Address - Fax:
Practice Address - Street 1:3250 HOGAN RD, SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-2830
Practice Address - Country:US
Practice Address - Phone:404-346-1526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001628225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist