Provider Demographics
NPI:1427308378
Name:LOVE, CHRISTAL (LMT)
Entity type:Individual
Prefix:
First Name:CHRISTAL
Middle Name:
Last Name:LOVE
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 1:5240 KATHERINE VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-4345
Mailing Address - Country:US
Mailing Address - Phone:770-282-7081
Mailing Address - Fax:
Practice Address - Street 1:5240 KATHERINE VILLAGE DR
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-4345
Practice Address - Country:US
Practice Address - Phone:770-282-7081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA101050225700000X
MO2015042566225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist