Provider Demographics
NPI:1629770136
Name:LOCKETT, KEANNA (LMT)
Entity Type:Individual
Prefix:
First Name:KEANNA
Middle Name:
Last Name:LOCKETT
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 1:1550 TERRELL MILL RD SE APT 25C
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-6079
Mailing Address - Country:US
Mailing Address - Phone:731-394-8179
Mailing Address - Fax:
Practice Address - Street 1:1550 TERRELL MILL RD SE APT 25C
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-6079
Practice Address - Country:US
Practice Address - Phone:731-394-8179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT01436225700000X
GAMT014036225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist