Provider Demographics
NPI:1205084308
Name:BENNETT, JOAN KAREN (LMT, MMP)
Entity type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:KAREN
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 OLD ALABAMA ROAD
Mailing Address - Street 2:SUITE 24
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-2400
Mailing Address - Country:US
Mailing Address - Phone:770-998-9009
Mailing Address - Fax:770-998-9071
Practice Address - Street 1:2500 OLD ALABAMA RD
Practice Address - Street 2:SUITE 24
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-2400
Practice Address - Country:US
Practice Address - Phone:770-998-9009
Practice Address - Fax:770-998-9701
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT000957174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAMT000957OtherMASSAGE THERAPY