Provider Demographics
NPI:1437646775
Name:DAVIS, MARY TERESA (LMT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:TERESA
Last Name:DAVIS
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 1:107 STONEY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:KATHLEEN
Mailing Address - State:GA
Mailing Address - Zip Code:31047-3119
Mailing Address - Country:US
Mailing Address - Phone:478-396-6658
Mailing Address - Fax:
Practice Address - Street 1:158 S HOUSTON LAKE RD STE 3
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-8018
Practice Address - Country:US
Practice Address - Phone:478-396-6658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT010968225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist