Provider Demographics
NPI:1588406532
Name:WALKER, JUSTIN LEE (LMT)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:LEE
Last Name:WALKER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4080 RIDGEBROOK BND
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30028-8185
Mailing Address - Country:US
Mailing Address - Phone:770-713-7984
Mailing Address - Fax:
Practice Address - Street 1:309 PIRKLE FERRY RD STE A100
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2547
Practice Address - Country:US
Practice Address - Phone:770-713-7984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT003162225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist