Provider Demographics
NPI:1679866131
Name:VIDARTE, ANA MARIA (LMT)
Entity Type:Individual
Prefix:
First Name:ANA
Middle Name:MARIA
Last Name:VIDARTE
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 1:2855 CRYSTAL BROOKE LN
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-4549
Mailing Address - Country:US
Mailing Address - Phone:678-777-7586
Mailing Address - Fax:770-982-2844
Practice Address - Street 1:8400 HOLCOMB BRIDGE RD
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-1837
Practice Address - Country:US
Practice Address - Phone:678-777-7586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT006953173C00000X, 2251E1200X, 225400000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist
No2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomics
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner