Provider Demographics
NPI:1770808545
Name:GWINN, KEISHA MONIQUE (MT)
Entity type:Individual
Prefix:MRS
First Name:KEISHA
Middle Name:MONIQUE
Last Name:GWINN
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 26TH ST NW
Mailing Address - Street 2:APT. 1117
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1914
Mailing Address - Country:US
Mailing Address - Phone:404-955-1000
Mailing Address - Fax:
Practice Address - Street 1:2221 PEACHTREE RD NE
Practice Address - Street 2:STE. P33
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1148
Practice Address - Country:US
Practice Address - Phone:404-955-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-05
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT004320225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist