Provider Demographics
NPI:1295262855
Name:DAUPHINAIS, TINA MICHELLE (LMT)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MICHELLE
Last Name:DAUPHINAIS
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:PO BOX 2120
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:GA
Mailing Address - Zip Code:31305-2120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1288 COX RD SW
Practice Address - Street 2:
Practice Address - City:TOWNSEND
Practice Address - State:GA
Practice Address - Zip Code:31331-7019
Practice Address - Country:US
Practice Address - Phone:678-977-3017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT000338225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist