Provider Demographics
NPI:1770873846
Name:GENNUSO, SETH (PTA)
Entity type:Individual
Prefix:MR
First Name:SETH
Middle Name:
Last Name:GENNUSO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1865 BOLD SPRINGS RD NW
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30656-4605
Mailing Address - Country:US
Mailing Address - Phone:706-267-8677
Mailing Address - Fax:
Practice Address - Street 1:1865 BOLD SPRINGS RD NW
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30656-4605
Practice Address - Country:US
Practice Address - Phone:706-267-8677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002497225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant