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General NPI Number Information
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NPI Number | 1619782802
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Entity Type | Individual
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Provider Name | ANDREW GRACEN
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Gender | Male
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Dates
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Enumeration Date | 02/12/2025
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Last Update Date | 02/12/2025
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Provider Practice Location Address
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Address Line | 3133 MAPLE DR NE
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City | ATLANTA
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State | GA
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Zip | 30305-2505
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Country | US
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Telephone | 404-220-7720
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Fax |
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Provider Business Mailing Address
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Address Line | 5480 WILLOW POINT PKWY
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City | MARIETTA
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State | GA
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Zip | 30068-1834
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Country | US
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Telephone |
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Fax |
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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 | 007120
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License Number State | GA
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