Provider Demographics
NPI:1184236259
Name:BROWN, JUSTIN TAYLOR (PTA)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:TAYLOR
Last Name:BROWN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 LANTERN LN
Mailing Address - Street 2:
Mailing Address - City:ELLERSLIE
Mailing Address - State:GA
Mailing Address - Zip Code:31807-5395
Mailing Address - Country:US
Mailing Address - Phone:706-573-9833
Mailing Address - Fax:
Practice Address - Street 1:106 ENTERPRISE CT
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-9227
Practice Address - Country:US
Practice Address - Phone:706-321-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA014907225100000X
GA002812225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist