Provider Demographics
NPI:1689916710
Name:GANTT, ALIX C (PT)
Entity Type:Individual
Prefix:
First Name:ALIX
Middle Name:C
Last Name:GANTT
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 1:5242 WINDMILL PL
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-6788
Mailing Address - Country:US
Mailing Address - Phone:706-945-0316
Mailing Address - Fax:706-860-8765
Practice Address - Street 1:211 BOBBY JONES EXPY
Practice Address - Street 2:STE C
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-5250
Practice Address - Country:US
Practice Address - Phone:706-860-3355
Practice Address - Fax:706-860-8765
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT003974225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist