Provider Demographics
NPI:1457901878
Name:GRIFFIN, BRENDA
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6112 PARK CLOSE
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-4674
Mailing Address - Country:US
Mailing Address - Phone:404-992-7118
Mailing Address - Fax:
Practice Address - Street 1:285 SUMMERLIN BLVD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-6272
Practice Address - Country:US
Practice Address - Phone:770-637-2207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-17
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002504225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist