Provider Demographics
NPI:1649515081
Name:THEODORIS, ANASTASIA
Entity type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:
Last Name:THEODORIS
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 1:425 RIDGEWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-4149
Mailing Address - Country:US
Mailing Address - Phone:770-377-9704
Mailing Address - Fax:
Practice Address - Street 1:6600 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:BUILDING 400, SUITE 125
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-6773
Practice Address - Country:US
Practice Address - Phone:678-587-9922
Practice Address - Fax:866-587-9993
Is Sole Proprietor?:No
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT002204225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist