Provider Demographics
NPI:1831331024
Name:WIEDRICH, GINA MARIE (MT)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:WIEDRICH
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 1:619 REDWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-7788
Mailing Address - Country:US
Mailing Address - Phone:678-880-7346
Mailing Address - Fax:
Practice Address - Street 1:2920 MARIETTA HWY STE 108
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-8207
Practice Address - Country:US
Practice Address - Phone:678-880-7346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-02
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT001530225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist