Provider Demographics
NPI:1295170959
Name:WILSON, SAMANTHA ELIZABETH (MASSAGE THERAPIST)
Entity type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:ELIZABETH
Last Name:WILSON
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2185 NORTHLAKE PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4100
Mailing Address - Country:US
Mailing Address - Phone:770-493-6360
Mailing Address - Fax:770-493-6350
Practice Address - Street 1:2185 NORTHLAKE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4100
Practice Address - Country:US
Practice Address - Phone:770-493-6360
Practice Address - Fax:770-493-6350
Is Sole Proprietor?:No
Enumeration Date:2013-05-07
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT004816225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAMT004816OtherSTATE LICENSE NUMBER