Provider Demographics
NPI:1902214141
Name:SOMATIC INTEGRATIVE THERAPY
Entity Type:Organization
Organization Name:SOMATIC INTEGRATIVE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO / FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:SHANDRENA
Authorized Official - Middle Name:HADJAMARA
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:470-222-4424
Mailing Address - Street 1:PO BOX 28893
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30358-0893
Mailing Address - Country:US
Mailing Address - Phone:470-222-4424
Mailing Address - Fax:
Practice Address - Street 1:284 HIGHWAY 314
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7832
Practice Address - Country:US
Practice Address - Phone:470-222-4424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:I CHOOSE HEALTH 360 LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007602225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty