Provider Demographics
NPI:1649608068
Name:DURHAM, DENISE NICOLE (PT)
Entity type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:NICOLE
Last Name:DURHAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:DENISE
Other - Middle Name:NICOLE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1035 GUNTER CT
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-3503
Mailing Address - Country:US
Mailing Address - Phone:770-846-6336
Mailing Address - Fax:847-386-5196
Practice Address - Street 1:2899 FIVE FORKS TRICKUM RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-5803
Practice Address - Country:US
Practice Address - Phone:770-982-9969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-22
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA55622251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics