Provider Demographics
NPI:1831141696
Name:CHACKO, ANITA GEORGE (PT)
Entity Type:Individual
Prefix:MRS
First Name:ANITA
Middle Name:GEORGE
Last Name:CHACKO
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 1:2100 SHILOH VALLEY DR NW
Mailing Address - Street 2:APT # 1427
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-4571
Mailing Address - Country:US
Mailing Address - Phone:678-528-7530
Mailing Address - Fax:
Practice Address - Street 1:26 TOWER RD NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-6947
Practice Address - Country:US
Practice Address - Phone:770-422-8913
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008158225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist