Provider Demographics
NPI:1790415065
Name:MARTTALA, LILLIAN GRACE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:GRACE
Last Name:MARTTALA
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:LILLY
Other - Middle Name:GRACE
Other - Last Name:MARTTALA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:2361 SANFORD RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5511
Mailing Address - Country:US
Mailing Address - Phone:931-607-2910
Mailing Address - Fax:
Practice Address - Street 1:3405 DALLAS HWY SW STE 601
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-6427
Practice Address - Country:US
Practice Address - Phone:770-438-5226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT015959225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist