Provider Demographics
NPI:1023461878
Name:PHILLIPS, CODY LEE (PTA)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:LEE
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-362-8684
Practice Address - Street 1:2300 BETHELVIEW RD
Practice Address - Street 2:STE 2013
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-9475
Practice Address - Country:US
Practice Address - Phone:770-888-1106
Practice Address - Fax:770-888-1653
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA003653225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant