Provider Demographics
NPI:1790352813
Name:PORTER, LEA ANN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:LEA ANN
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 WISTERIA DR STE A
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-2689
Mailing Address - Country:US
Mailing Address - Phone:770-982-0102
Mailing Address - Fax:770-982-0130
Practice Address - Street 1:4220 MUNDY MILL PL STE 2B
Practice Address - Street 2:
Practice Address - City:OAKWOOD
Practice Address - State:GA
Practice Address - Zip Code:30566-2573
Practice Address - Country:US
Practice Address - Phone:678-450-9933
Practice Address - Fax:678-450-9966
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT015295225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist