Provider Demographics
NPI:1487256731
Name:KING, CARISA CHREE (MASSAGE THERAPIST)
Entity type:Individual
Prefix:
First Name:CARISA
Middle Name:CHREE
Last Name:KING
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2141 KINGSTON CT SE STE 111
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8928
Mailing Address - Country:US
Mailing Address - Phone:470-999-0392
Mailing Address - Fax:
Practice Address - Street 1:2141 KINGSTON CT SE STE 111
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8928
Practice Address - Country:US
Practice Address - Phone:470-999-0392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT011526225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA052887721OtherMASSAGE THERAPIST