Provider Demographics
NPI:1134424567
Name:CADDELL, DEBBRA HOLDER (LMT)
Entity type:Individual
Prefix:
First Name:DEBBRA
Middle Name:HOLDER
Last Name:CADDELL
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 1:215 BANKS STA
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7505
Mailing Address - Country:US
Mailing Address - Phone:770-719-4949
Mailing Address - Fax:
Practice Address - Street 1:215 BANKS STA
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7505
Practice Address - Country:US
Practice Address - Phone:770-719-4949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-15
Last Update Date:2011-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT002429225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist