Doctor Name: | BEVERLY WILSON |
NPI Number: | 1720386451 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | LMT |
License Number: | MT006291 |
Business Practice Address: | 700 Dalrymple Rd 203 Atlanta, GA - 303281414 |
Business Phone Number: | 4049400784 |
Business Fax Number: | |
Mailing Address: | Po Box 291, ELLENWOOD |
State: | GA |
Postal Code: | 302940291 |
Phone Number: | 4049400784 |
Fax Number: | |
NPI Enumeration Date: | 03/03/2011 |
NPI Last Update Date: | 04/14/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 225700000X |
License Number: | MT006291 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | GA |
Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
Taxonomy Classification: | Massage Therapist |
Taxonomy Specialization: | |
Taxonomy Definition: | An individual trained in the manipulation of tissues (as by rubbing, stroking, kneading, or tapping) with the hand or an instrument for remedial or hygienic purposes. |