Provider Demographics
NPI:1750590410
Name:LAVENDER, ROBERT BRADLEY (PT, ATC)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:BRADLEY
Last Name:LAVENDER
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:386 E CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ELBERTON
Mailing Address - State:GA
Mailing Address - Zip Code:30635-2463
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 HEARD ST STE B
Practice Address - Street 2:
Practice Address - City:ELBERTON
Practice Address - State:GA
Practice Address - Zip Code:30635-2436
Practice Address - Country:US
Practice Address - Phone:706-213-8506
Practice Address - Fax:706-213-0335
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT006983225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist