Provider Demographics
NPI:1083482632
Name:PHILLIPS, LMT CMLDT, SUZANNE (LMT, CMLDT)
Entity Type:Individual
Prefix:MISS
First Name:SUZANNE
Middle Name:
Last Name:PHILLIPS, LMT CMLDT
Suffix:
Gender:F
Credentials:LMT, CMLDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8228 ORKNEY WAY
Mailing Address - Street 2:
Mailing Address - City:WINSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30187-1312
Mailing Address - Country:US
Mailing Address - Phone:404-202-6506
Mailing Address - Fax:
Practice Address - Street 1:8697 HOSPITAL DR STE 202
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2220
Practice Address - Country:US
Practice Address - Phone:404-402-9985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT013998225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist