Provider Demographics
NPI:1972826899
Name:DAVIS, CAROLYN T (LMT NCTMB SET)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:T
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LMT NCTMB SET
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:582 MACKENZIE CT
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-2385
Mailing Address - Country:US
Mailing Address - Phone:678-462-2972
Mailing Address - Fax:
Practice Address - Street 1:1130 HURRICANE SHOALS RD NE
Practice Address - Street 2:SUITE 1900
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-4851
Practice Address - Country:US
Practice Address - Phone:678-462-2972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-05
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT001114225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAMT001114OtherMASSAGE LICENSE
GA2008002671OtherGWINNETT COUNTY BUSINESS LICENSE
538877-07OtherNATIONAL CERTIFICATION OF THERAPEUTIC MASSAGE & BODYWORK