Provider Demographics
NPI:1699222893
Name:DUDEN, EMILY (LMT)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:DUDEN
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 1:158 S HOUSTON LAKE RD
Mailing Address - Street 2:STE 2
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-8017
Mailing Address - Country:US
Mailing Address - Phone:478-202-7260
Mailing Address - Fax:
Practice Address - Street 1:158 S HOUSTON LAKE RD
Practice Address - Street 2:STE 2
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-8017
Practice Address - Country:US
Practice Address - Phone:478-202-7260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT009570173C00000X
GAMT9570225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAMT009570OtherLICENSED MASSAGE THERAPST