=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053600973
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEORGIA MCLEAN LMBT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2011
-----------------------------------------------------
Last Update Date | 03/31/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2850 TYNECASTLE HWY
-----------------------------------------------------
City | BANNER ELK
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28604-9716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-964-3387
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1647
-----------------------------------------------------
City | BANNER ELK
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28604-1647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-964-3387
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 9600
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------