Provider Demographics
NPI:1366222846
Name:ALVIN, MONIQUE (LMT)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:ALVIN
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 1:16 TWELVE OAKS RD
Mailing Address - Street 2:
Mailing Address - City:PORT WENTWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:31407-6009
Mailing Address - Country:US
Mailing Address - Phone:912-944-7126
Mailing Address - Fax:
Practice Address - Street 1:5910 GA HIGHWAY 21 S
Practice Address - Street 2:
Practice Address - City:RINCON
Practice Address - State:GA
Practice Address - Zip Code:31326-5505
Practice Address - Country:US
Practice Address - Phone:912-944-7136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-03
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT007691225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist