Provider Demographics
NPI:1295802502
Name:LEVERETTE, COY III (MPT)
Entity type:Individual
Prefix:MR
First Name:COY
Middle Name:
Last Name:LEVERETTE
Suffix:III
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 VININGS DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-5978
Mailing Address - Country:US
Mailing Address - Phone:770-288-2441
Mailing Address - Fax:770-288-2442
Practice Address - Street 1:106 VININGS DR
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-5978
Practice Address - Country:US
Practice Address - Phone:770-288-2441
Practice Address - Fax:770-288-2442
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0085172251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBDMWMedicare ID - Type UnspecifiedPHYSICAL THERAPY