Healthcare Provider Details

I. General information

NPI: 1295262855
Provider Name (Legal Business Name): TINA MICHELLE DAUPHINAIS LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1288 COX RD SW
TOWNSEND GA
31331-7019
US

IV. Provider business mailing address

PO BOX 2120
DARIEN GA
31305-2120
US

V. Phone/Fax

Practice location:
  • Phone: 678-977-3017
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT000338
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: