Provider Demographics
NPI:1568931798
Name:GAULDING, DALE LANE
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:LANE
Last Name:GAULDING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 W PEACHTREE ST NW APT 642
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-4784
Mailing Address - Country:US
Mailing Address - Phone:256-283-6770
Mailing Address - Fax:
Practice Address - Street 1:3161 HOWELL MILL RD NW STE 400
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-2117
Practice Address - Country:US
Practice Address - Phone:404-478-2399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-16
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT003113225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist