Provider Demographics
NPI:1811532484
Name:WIDMER, JULIE (LMT)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:WIDMER
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 1:243 BIRCH CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-7258
Mailing Address - Country:US
Mailing Address - Phone:770-681-5001
Mailing Address - Fax:
Practice Address - Street 1:417 S 6TH ST STE B
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4319
Practice Address - Country:US
Practice Address - Phone:770-681-5001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT012031225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist