Healthcare Provider Details

I. General information

NPI: 1790602308
Provider Name (Legal Business Name): STORMY LOVIE DAVENPORT MASSAGE THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2026
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

923 PINE OAK TRL
AUSTELL GA
30168-7019
US

IV. Provider business mailing address

3763 OLSON DR
AUSTELL GA
30106-1776
US

V. Phone/Fax

Practice location:
  • Phone: 403-561-4860
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number013693
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: