Provider Demographics
NPI:1720559693
Name:REESE, ANGELA DENISE (LMT, LE)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:DENISE
Last Name:REESE
Suffix:
Gender:F
Credentials:LMT, LE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1751 MISSELTHRUSH LN
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-3084
Mailing Address - Country:US
Mailing Address - Phone:224-456-9886
Mailing Address - Fax:
Practice Address - Street 1:807 PAVILION CT
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-6666
Practice Address - Country:US
Practice Address - Phone:224-456-9886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT011537225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty