Provider Demographics
NPI:1467889998
Name:MASOCOL, TANYA (LMT)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:MASOCOL
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 1:770 OLD ROSWELL PL
Mailing Address - Street 2:SUITE I-400
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-1670
Mailing Address - Country:US
Mailing Address - Phone:770-906-2265
Mailing Address - Fax:
Practice Address - Street 1:770 OLD ROSWELL PL
Practice Address - Street 2:SUITE I-400
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1670
Practice Address - Country:US
Practice Address - Phone:770-906-2265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT006794225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist