Provider Demographics
NPI:1558719146
Name:GARDNER, GHAFFARAH (LMT)
Entity Type:Individual
Prefix:
First Name:GHAFFARAH
Middle Name:
Last Name:GARDNER
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 1:414 PONCE DE LEON AVE NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-2015
Mailing Address - Country:US
Mailing Address - Phone:404-457-2000
Mailing Address - Fax:
Practice Address - Street 1:2850 DELK RD SE
Practice Address - Street 2:36G
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-5352
Practice Address - Country:US
Practice Address - Phone:404-457-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT009604225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist