Provider Demographics
NPI:1871215608
Name:PACE, CARSON CROWLEY
Entity type:Individual
Prefix:
First Name:CARSON
Middle Name:CROWLEY
Last Name:PACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 DIAMOND RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-7126
Mailing Address - Country:US
Mailing Address - Phone:706-306-7552
Mailing Address - Fax:
Practice Address - Street 1:1100 REINHARDT COLLEGE PKWY
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2011
Practice Address - Country:US
Practice Address - Phone:770-721-2812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT013986225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty