Provider Demographics
NPI:1720386451
Name:WILSON, BEVERLY (LMT)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:WILSON
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:PO BOX 291
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-0291
Mailing Address - Country:US
Mailing Address - Phone:404-940-0784
Mailing Address - Fax:
Practice Address - Street 1:700 DALRYMPLE RD
Practice Address - Street 2:203
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-1414
Practice Address - Country:US
Practice Address - Phone:404-940-0784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-03
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT006291225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist