Provider Demographics
NPI:1578910964
Name:SERVILLE, JOANNE
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:
Last Name:SERVILLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOANNE
Other - Middle Name:
Other - Last Name:JOSEPH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:730 WINDCHASE LN
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-6328
Mailing Address - Country:US
Mailing Address - Phone:404-391-9098
Mailing Address - Fax:
Practice Address - Street 1:730 WINDCHASE LN
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-6328
Practice Address - Country:US
Practice Address - Phone:404-391-9098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-16
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT006929225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist