Provider Demographics
NPI:1619446150
Name:DUNN, MARY GIBSON (LMT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GIBSON
Last Name:DUNN
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 1:2052 TOWNSHIP DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-5284
Mailing Address - Country:US
Mailing Address - Phone:859-338-4656
Mailing Address - Fax:
Practice Address - Street 1:6884 HICKORY FLAT HWY
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3229
Practice Address - Country:US
Practice Address - Phone:770-704-8244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT010096225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist