MEDICARE: MISS DESTINY WOOD LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MT013485	GA

General Provider Information

NPI Number	:	1154087179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS DESTINY WOOD LMT

Provider Business Mailing Address
First Line	:	261 RALPH DAVID ABERNATHY BLVD SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30312-2634
Country	:	US
Telephone Number	:	770-330-7903
Fax Number	:

Provider Business Practice Location Address
First Line	:	3133 MAPLE DR NE STE 120
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30305-2509
Country	:	US
Telephone Number	:	770-330-7903
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2021
Last Update Date	:	11/14/2021

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Directions to “ MISS DESTINY WOOD LMT” Practice Location

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