Provider Demographics
NPI:1760152151
Name:SKINNER, MACIE JO (MT-BC, LPMT)
Entity Type:Individual
Prefix:
First Name:MACIE
Middle Name:JO
Last Name:SKINNER
Suffix:
Gender:F
Credentials:MT-BC, LPMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 VILLA MAGNOLIA LN
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-3231
Mailing Address - Country:US
Mailing Address - Phone:678-372-0392
Mailing Address - Fax:
Practice Address - Street 1:9880 HICKORY FLAT HWY
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3081
Practice Address - Country:US
Practice Address - Phone:770-687-2542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMUT000257225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist