Provider Demographics
NPI:1558021550
Name:LOPES, GIANNA (PTA)
Entity Type:Individual
Prefix:
First Name:GIANNA
Middle Name:
Last Name:LOPES
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 1:20A SMITH BLVD
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-6093
Mailing Address - Country:US
Mailing Address - Phone:843-251-8150
Mailing Address - Fax:
Practice Address - Street 1:176 VILLAGE CENTER BLVD
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-6618
Practice Address - Country:US
Practice Address - Phone:843-547-5272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-19
Last Update Date:2022-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA5616225200000X
SC4401225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant