Basic Information
| Provider Information | |||||||||
| NPI: | 1275015083 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GACEK | ||||||||
| FirstName: | MARISSA | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 370 | ||||||||
| Address2: | |||||||||
| City: | FORTSON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 318080370 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2463 HAMILTON MILL PKWY STE 250 | ||||||||
| Address2: | |||||||||
| City: | DACULA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300194647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709329521 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2018 | ||||||||
| LastUpdateDate: | 02/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT013605 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PTH10662 | AL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.