Provider Demographics
NPI:1881076982
Name:IN-HOME PHYSICAL THERAPY
Entity type:Organization
Organization Name:IN-HOME PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT
Authorized Official - Prefix:
Authorized Official - First Name:MARIA SHEILA
Authorized Official - Middle Name:LAJA
Authorized Official - Last Name:CAMPANANO
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, WCC, CI
Authorized Official - Phone:770-601-8984
Mailing Address - Street 1:1128 HARVEST BROOK DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-4743
Mailing Address - Country:US
Mailing Address - Phone:770-601-8984
Mailing Address - Fax:770-574-4428
Practice Address - Street 1:1128 HARVEST BROOK DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-4743
Practice Address - Country:US
Practice Address - Phone:770-601-8984
Practice Address - Fax:770-574-4428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-24
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA315889908AMedicaid