Healthcare Provider Details

I. General information

NPI: 1881308922
Provider Name (Legal Business Name): MARJORIE YVONNE BAER LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2023
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 GRIFFIN ST
GRANTVILLE GA
30220-2051
US

IV. Provider business mailing address

PO BOX 183
GRANTVILLE GA
30220-0183
US

V. Phone/Fax

Practice location:
  • Phone: 678-576-6530
  • Fax:
Mailing address:
  • Phone: 678-576-6530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT002407
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: