MEDICARE: KEISHA NICOLE MCCLURE 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	MT012547	GA

General Provider Information

NPI Number	:	1174487219
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEISHA NICOLE MCCLURE LMT

Provider Business Mailing Address
First Line	:	3625 DALLAS HWY SW STE 840
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30064-5924
Country	:	US
Telephone Number	:	678-571-1203
Fax Number	:

Provider Business Practice Location Address
First Line	:	3625 DALLAS HWY SW STE 840
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30064-5924
Country	:	US
Telephone Number	:	678-571-1203
Fax Number	:

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

Provider Enumeration Date	:	12/12/2025
Last Update Date	:	12/12/2025

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