Provider Demographics
NPI:1780031245
Name:STANLEY, LINDA JEANNETTE (LMT)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:JEANNETTE
Last Name:STANLEY
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 1:29 NORTH AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-3564
Mailing Address - Country:US
Mailing Address - Phone:706-698-7140
Mailing Address - Fax:
Practice Address - Street 1:29 NORTH AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-3564
Practice Address - Country:US
Practice Address - Phone:706-698-7140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-14
Last Update Date:2016-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT010421225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist