Provider Demographics
NPI:1538381942
Name:FORDYCE, ELIZABETH (PT)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:FORDYCE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:
Other - Last Name:FORDYCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4434 SIMS CT
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-3111
Mailing Address - Country:US
Mailing Address - Phone:770-908-1526
Mailing Address - Fax:
Practice Address - Street 1:1441 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1004
Practice Address - Country:US
Practice Address - Phone:404-712-5527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT005618225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist