MEDICARE: SOMATIC INTEGRATIVE THERAPY

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	007602	GA

General Provider Information

NPI Number	:	1902214141
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOMATIC INTEGRATIVE THERAPY

Provider Business Mailing Address
First Line	:	PO BOX 28893
Second Line	:
City	:	SANDY SPRINGS
State	:	GA
Zip	:	30358-0893
Country	:	US
Telephone Number	:	470-222-4424
Fax Number	:

Provider Business Practice Location Address
First Line	:	284 HIGHWAY 314
Second Line	:
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30214-7832
Country	:	US
Telephone Number	:	470-222-4424
Fax Number	:

Authorized Official
Title or Position	:	CEO / FOUNDER
Name	:	SHANDRENA HADJAMARA WILLIAMS
Credential	:	LMT
Telephone Number	:	470-222-4424

Provider Enumeration Date	:	07/31/2014
Last Update Date	:	07/31/2014

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