Healthcare Provider Details

I. General information

NPI: 1659282085
Provider Name (Legal Business Name): TERRY DENISE MACKLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 CLARENDON PL # 305
FAYETTEVILLE GA
30215-2238
US

IV. Provider business mailing address

305 CLARENDON PL # 305
FAYETTEVILLE GA
30215-2238
US

V. Phone/Fax

Practice location:
  • Phone: 678-427-0816
  • Fax:
Mailing address:
  • Phone: 678-427-0816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT001255
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: