Provider Demographics
NPI:1700593274
Name:BENNITTS, JUSTIN DANIEL (LMT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DANIEL
Last Name:BENNITTS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:JUSTIN
Other - Middle Name:DANIEL
Other - Last Name:MITTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:1391 GORDON RD
Mailing Address - Street 2:
Mailing Address - City:MORELAND
Mailing Address - State:GA
Mailing Address - Zip Code:30259-2541
Mailing Address - Country:US
Mailing Address - Phone:931-257-4760
Mailing Address - Fax:
Practice Address - Street 1:354 NEWNAN CROSSING BYP STE B
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2323
Practice Address - Country:US
Practice Address - Phone:470-400-1980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-03
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT011129225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist