Healthcare Provider Details

I. General information

NPI: 1114207164
Provider Name (Legal Business Name): MARY D HUTTON L.M.T., N.C.T.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2011
Last Update Date: 08/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 REGISTRY TER NW
KENNESAW GA
30152-2855
US

IV. Provider business mailing address

825 REGISTRY TER NW
KENNESAW GA
30152-2855
US

V. Phone/Fax

Practice location:
  • Phone: 770-429-0208
  • Fax: 404-745-0707
Mailing address:
  • Phone: 770-429-0208
  • Fax: 404-745-0707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMT001419
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: