Healthcare Provider Details

I. General information

NPI: 1013848670
Provider Name (Legal Business Name): MIRIAM ALEESE PERCELL CUMMINGS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4165 CHAPEL MILL WAY
DECATUR GA
30034-5338
US

IV. Provider business mailing address

4165 CHAPEL MILL WAY
DECATUR GA
30034-5338
US

V. Phone/Fax

Practice location:
  • Phone: 678-521-0334
  • Fax:
Mailing address:
  • Phone: 678-521-0334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT0095897
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: