Provider Demographics
NPI:1710949615
Name:REDD, TINA M (PT)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:REDD
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 1:270 CHASTAIN RD NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-3012
Mailing Address - Country:US
Mailing Address - Phone:678-678-5946
Mailing Address - Fax:678-594-6081
Practice Address - Street 1:270 CHASTAIN RD NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-3012
Practice Address - Country:US
Practice Address - Phone:678-678-5946
Practice Address - Fax:678-594-6081
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0018642251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBCBRMedicare ID - Type Unspecified