Provider Demographics
NPI:1790250827
Name:RAY, RICHARD JAMES (PTA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JAMES
Last Name:RAY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 JUNIPER ST NE APT 1520
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-2162
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:530 THORNTON RD # 210
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-4120
Practice Address - Country:US
Practice Address - Phone:404-855-2141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA004107225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant