Provider Demographics
NPI:1861439200
Name:BURGESS, BRENDA J LIPSCOMB (PT)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:J LIPSCOMB
Last Name:BURGESS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:J
Other - Last Name:LIPSCOMB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6397 LEE HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-4915
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:561 THORNTON RD STE M
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-1558
Practice Address - Country:US
Practice Address - Phone:770-575-3154
Practice Address - Fax:770-635-8444
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT001095225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBDDXMedicare ID - Type Unspecified