Provider Demographics
NPI:1013253780
Name:EZEANYA, CLARICE M (DPT)
Entity type:Individual
Prefix:MRS
First Name:CLARICE
Middle Name:M
Last Name:EZEANYA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 BAKERS MILL RD
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-2958
Mailing Address - Country:US
Mailing Address - Phone:862-202-6596
Mailing Address - Fax:
Practice Address - Street 1:302 SATELLITE BLVD NE STE 111
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-7182
Practice Address - Country:US
Practice Address - Phone:862-202-6596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-27
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01471200225100000X
GAPT011257225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist