Provider Demographics
NPI:1790596906
Name:KING, ELYSSIA (PT)
Entity type:Individual
Prefix:
First Name:ELYSSIA
Middle Name:
Last Name:KING
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 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:423-541-5846
Mailing Address - Fax:
Practice Address - Street 1:1820 HIGHWAY 20 SE STE 160
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2080
Practice Address - Country:US
Practice Address - Phone:770-929-8872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-16
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT017563225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist