Provider Demographics
NPI:1639523350
Name:COSTOMIRIS, JULIE MILLER (PT)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:MILLER
Last Name:COSTOMIRIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 ED MOORE CT
Mailing Address - Street 2:SUITE B
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-5024
Mailing Address - Country:US
Mailing Address - Phone:912-764-9951
Mailing Address - Fax:912-489-4808
Practice Address - Street 1:2 ED MOORE CT
Practice Address - Street 2:SUITE B
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5024
Practice Address - Country:US
Practice Address - Phone:912-764-9951
Practice Address - Fax:912-489-4808
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT005739225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist