Provider Demographics
NPI:1174294508
Name:DYSON, JAMES EDWARD
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:EDWARD
Last Name:DYSON
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JIM
Other - Middle Name:EDWARD
Other - Last Name:DYSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT LICENSED MASSAGE
Mailing Address - Street 1:790 QUAILWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-1450
Mailing Address - Country:US
Mailing Address - Phone:706-338-2178
Mailing Address - Fax:
Practice Address - Street 1:345 RESOURCE PKWY
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-8364
Practice Address - Country:US
Practice Address - Phone:706-338-2178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT000841225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist