Healthcare Provider Details

I. General information

NPI: 1679866131
Provider Name (Legal Business Name): ANA MARIA VIDARTE L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2011
Last Update Date: 05/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8400 HOLCOMB BRIDGE RD
ALPHARETTA GA
30022-1837
US

IV. Provider business mailing address

2855 CRYSTAL BROOKE LN
SNELLVILLE GA
30078-4549
US

V. Phone/Fax

Practice location:
  • Phone: 678-777-7586
  • Fax:
Mailing address:
  • Phone: 678-777-7586
  • Fax: 770-982-2844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License NumberMT006953
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2251E1200X
TaxonomyErgonomics Physical Therapist
License NumberMT006953
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberMT006953
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT006953
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: