Provider Demographics
NPI:1144639238
Name:GUSTIN, AMANDA (PT, DPT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GUSTIN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 PACES FERRY RD SE
Mailing Address - Street 2:STE 478
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-5790
Mailing Address - Country:US
Mailing Address - Phone:404-479-1739
Mailing Address - Fax:404-479-1739
Practice Address - Street 1:3005 OLD ALABAMA RD
Practice Address - Street 2:BUILDING E SUITE 10
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30022-8594
Practice Address - Country:US
Practice Address - Phone:770-552-8852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT011553225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist