Provider Demographics
NPI:1659538429
Name:IBANEZ, AILEEN (MPT)
Entity Type:Individual
Prefix:
First Name:AILEEN
Middle Name:
Last Name:IBANEZ
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:849 PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31211-1422
Mailing Address - Country:US
Mailing Address - Phone:478-238-9641
Mailing Address - Fax:
Practice Address - Street 1:2249 VINSON HWY SE
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-4807
Practice Address - Country:US
Practice Address - Phone:478-453-0163
Practice Address - Fax:478-453-0164
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0076622251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics