Healthcare Provider Details

I. General information

NPI: 1912826868
Provider Name (Legal Business Name): BRENDA IVETTE GARCIA PADUA LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 OAKEY ALY
DEMOREST GA
30535-4588
US

IV. Provider business mailing address

1302 OAKEY ALY
DEMOREST GA
30535-4588
US

V. Phone/Fax

Practice location:
  • Phone: 445-278-6383
  • Fax:
Mailing address:
  • Phone: 445-278-6383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT015941
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: