Healthcare Provider Details

I. General information

NPI: 1275877672
Provider Name (Legal Business Name): TASIA DOCKERY MT-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12010 ETRIS RD A-150
ROSWELL GA
30075-1421
US

IV. Provider business mailing address

1382 CHATLEY WAY
WOODSTOCK GA
30188-5527
US

V. Phone/Fax

Practice location:
  • Phone: 678-223-3987
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number10500
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: