Provider Demographics
NPI:1598246936
Name:YANG, SOO (MT)
Entity Type:Individual
Prefix:
First Name:SOO
Middle Name:
Last Name:YANG
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4411 SUWANEE DAM RD STE 330
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-8702
Mailing Address - Country:US
Mailing Address - Phone:770-904-2332
Mailing Address - Fax:770-904-2395
Practice Address - Street 1:4411 SUWANEE DAM RD STE 330
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-8702
Practice Address - Country:US
Practice Address - Phone:770-904-2332
Practice Address - Fax:770-904-2395
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT003971225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist