Provider Demographics
NPI:1265003453
Name:STALLWORTH, BRENNA JILL (PT)
Entity type:Individual
Prefix:
First Name:BRENNA
Middle Name:JILL
Last Name:STALLWORTH
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 1:6168 WINDFLOWER DR
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-8321
Mailing Address - Country:US
Mailing Address - Phone:770-377-2927
Mailing Address - Fax:
Practice Address - Street 1:3114 COBB PKWY NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-1017
Practice Address - Country:US
Practice Address - Phone:770-377-2927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT009395225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist