Provider Demographics
NPI:1780097295
Name:THURSTON, GENA MARIE (PT)
Entity type:Individual
Prefix:
First Name:GENA
Middle Name:MARIE
Last Name:THURSTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 W MADISON ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-4511
Mailing Address - Country:US
Mailing Address - Phone:312-624-8102
Mailing Address - Fax:312-496-3175
Practice Address - Street 1:1163 JOHNSON FERRY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-2764
Practice Address - Country:US
Practice Address - Phone:770-321-0155
Practice Address - Fax:770-321-8426
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10036225100000X
GAPT011939225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist