Provider Demographics
NPI:1659937761
Name:MACKIE, MICHAEL TYRONE (LPTA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TYRONE
Last Name:MACKIE
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2541 WINTERVILLE DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-0623
Mailing Address - Country:US
Mailing Address - Phone:706-231-7686
Mailing Address - Fax:
Practice Address - Street 1:2541 WINTERVILLE DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-0623
Practice Address - Country:US
Practice Address - Phone:706-231-7686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA000398225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant