Provider Demographics
NPI:1669259776
Name:WILLIAMS, TAHANNIE (LMT)
Entity type:Individual
Prefix:
First Name:TAHANNIE
Middle Name:
Last Name:WILLIAMS
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 1:2137 HICKORY BND SE APT B
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-2117
Mailing Address - Country:US
Mailing Address - Phone:770-349-5990
Mailing Address - Fax:
Practice Address - Street 1:2111 FLAT SHOALS RD SE STE 102
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-1826
Practice Address - Country:US
Practice Address - Phone:470-989-2473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT013099225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist