Healthcare Provider Details

I. General information

NPI: 1114107117
Provider Name (Legal Business Name): PATTI DENIKE NCTMB THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2007
Last Update Date: 11/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 COTTONWOOD ST
CLAYTON GA
30525-0000
US

IV. Provider business mailing address

PO BOX 396
LAKEMONT GA
30552-0007
US

V. Phone/Fax

Practice location:
  • Phone: 706-490-3149
  • Fax: 706-782-5266
Mailing address:
  • Phone: 706-490-3149
  • Fax: 706-782-5266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT000089
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: