Provider Demographics
NPI:1639040306
Name:GILES, CARISSA GRACE (PT, DPT)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:GRACE
Last Name:GILES
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 1:1502 DAVENPORT RD
Mailing Address - Street 2:
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517-2035
Mailing Address - Country:US
Mailing Address - Phone:706-765-4325
Mailing Address - Fax:
Practice Address - Street 1:428 S ENOTA DR NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2548
Practice Address - Country:US
Practice Address - Phone:678-616-3099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-16
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT018014225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist