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General NPI Number Information
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NPI Number | 1427425347
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Entity Type | Individual
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Provider Name | BRIAN DOUGLAS WALTERS LMT
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Gender | Male
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Dates
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Enumeration Date | 08/26/2015
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Last Update Date | 08/26/2015
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Provider Practice Location Address
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Address Line | 2045 ROCKBRIDGE RD
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City | STONE MOUNTAIN
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State | GA
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Zip | 30087-3551
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Country | US
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Telephone | 678-883-2873
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Fax |
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Provider Business Mailing Address
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Address Line | 4018 SUE LN
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City | DECATUR
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State | GA
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Zip | 30035-1075
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Country | US
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Telephone | 404-438-4477
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Fax | 800-975-1805
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MT007445
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License Number State | GA
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