Provider Demographics
NPI:1720230436
Name:WALCOTT, SAFIYAH (NMT)
Entity Type:Individual
Prefix:
First Name:SAFIYAH
Middle Name:
Last Name:WALCOTT
Suffix:
Gender:F
Credentials:NMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1399 SCENIC HWY N
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-2125
Mailing Address - Country:US
Mailing Address - Phone:770-985-9995
Mailing Address - Fax:
Practice Address - Street 1:5813 BOBBIN LN
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-5410
Practice Address - Country:US
Practice Address - Phone:404-917-9348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT000795225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist