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General NPI Number Information
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NPI Number | 1720386451
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Entity Type | Individual
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Provider Name | BEVERLY WILSON LMT
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Gender | Female
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Dates
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Enumeration Date | 03/03/2011
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Last Update Date | 04/14/2015
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Provider Practice Location Address
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Address Line | 700 DALRYMPLE RD 203
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City | ATLANTA
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State | GA
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Zip | 30328-1414
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Country | US
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Telephone | 404-940-0784
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 291
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City | ELLENWOOD
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State | GA
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Zip | 30294-0291
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Country | US
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Telephone | 404-940-0784
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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 | MT006291
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License Number State | GA
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