Healthcare Provider Details

I. General information

NPI: 1619446150
Provider Name (Legal Business Name): MARY GIBSON DUNN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2018
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6884 HICKORY FLAT HWY
WOODSTOCK GA
30188-3229
US

IV. Provider business mailing address

2052 TOWNSHIP DR
WOODSTOCK GA
30189-5284
US

V. Phone/Fax

Practice location:
  • Phone: 770-704-8244
  • Fax:
Mailing address:
  • Phone: 859-338-4656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT010096
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: