Provider Demographics
NPI:1932220266
Name:MOUNTAIN PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:MOUNTAIN PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHERISSE
Authorized Official - Middle Name:M
Authorized Official - Last Name:SANSONE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:706-782-2585
Mailing Address - Street 1:PO BOX 1397
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:GA
Mailing Address - Zip Code:30525-0035
Mailing Address - Country:US
Mailing Address - Phone:706-782-2585
Mailing Address - Fax:
Practice Address - Street 1:1218 NORTH MAIN ST
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:GA
Practice Address - Zip Code:30525
Practice Address - Country:US
Practice Address - Phone:706-782-2585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT006931225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00961111AMedicaid
GAGRP4514Medicare UPIN