Provider Demographics
NPI:1154087179
Name:WOOD, DESTINY (LMT)
Entity Type:Individual
Prefix:MISS
First Name:DESTINY
Middle Name:
Last Name:WOOD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 RALPH DAVID ABERNATHY BLVD SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-2634
Mailing Address - Country:US
Mailing Address - Phone:770-330-7903
Mailing Address - Fax:
Practice Address - Street 1:3133 MAPLE DR NE STE 120
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-2509
Practice Address - Country:US
Practice Address - Phone:770-330-7903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-14
Last Update Date:2021-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT013485225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty