Provider Demographics
NPI:1033687322
Name:BEARDEN, MATTIE M (LMT, FMT)
Entity Type:Individual
Prefix:
First Name:MATTIE
Middle Name:M
Last Name:BEARDEN
Suffix:
Gender:F
Credentials:LMT, FMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 BATTLEFIELD PKWY
Mailing Address - Street 2:
Mailing Address - City:FORT OGLETHORPE
Mailing Address - State:GA
Mailing Address - Zip Code:30742-4012
Mailing Address - Country:US
Mailing Address - Phone:423-710-5761
Mailing Address - Fax:
Practice Address - Street 1:1404 BATTLEFIELD PKWY
Practice Address - Street 2:
Practice Address - City:FORT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-4012
Practice Address - Country:US
Practice Address - Phone:423-710-5761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT010004225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist