Provider Demographics
NPI:1689730319
Name:SUTHERLAND PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:SUTHERLAND PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:JENNIFER
Authorized Official - Last Name:SUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:229-292-7426
Mailing Address - Street 1:5108 NORTHWIND BLVD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-7672
Mailing Address - Country:US
Mailing Address - Phone:229-244-1201
Mailing Address - Fax:229-244-1207
Practice Address - Street 1:5108 NORTHWIND BLVD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-7672
Practice Address - Country:US
Practice Address - Phone:229-244-1201
Practice Address - Fax:229-244-1207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0074692251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000957635CMedicaid