MEDICARE: PATTI DENIKE NCTMB THERAPIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MT000089	GA

General Provider Information

NPI Number	:	1114107117
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATTI DENIKE NCTMB THERAPIST

Provider Business Mailing Address
First Line	:	PO BOX 396
Second Line	:
City	:	LAKEMONT
State	:	GA
Zip	:	30552-0007
Country	:	US
Telephone Number	:	706-490-3149
Fax Number	:	706-782-5266

Provider Business Practice Location Address
First Line	:	44 COTTONWOOD ST
Second Line	:
City	:	CLAYTON
State	:	GA
Zip	:	30525-0000
Country	:	US
Telephone Number	:	706-490-3149
Fax Number	:	706-782-5266

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2007
Last Update Date	:	11/07/2007

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