Basic Information
| Provider Information | |||||||||
| NPI: | 1942681432 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | MADISON | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5513 CHAMBLEE DUNWOODY RD | ||||||||
| Address2: | SUITE 430 | ||||||||
| City: | DUNWOODY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303384106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705519633 | ||||||||
| FaxNumber: | 7706989184 | ||||||||
| Practice Location | |||||||||
| Address1: | 5513 CHAMBLEE DUNWOODY RD | ||||||||
| Address2: | SUITE 430 | ||||||||
| City: | DUNWOODY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303384106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705519633 | ||||||||
| FaxNumber: | 7706989184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2015 | ||||||||
| LastUpdateDate: | 07/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 011949 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.