Healthcare Provider Details

I. General information

NPI: 1760215305
Provider Name (Legal Business Name): MELISSA OBRYAN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4155 LAKE ST
ALPHARETTA GA
30009-3917
US

IV. Provider business mailing address

4155 LAKE ST
ALPHARETTA GA
30009-3917
US

V. Phone/Fax

Practice location:
  • Phone: 404-593-8560
  • Fax:
Mailing address:
  • Phone: 404-593-8560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT004815
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: