Provider Demographics
NPI:1245101955
Name:CHENNAULT, GENEVA
Entity type:Individual
Prefix:
First Name:GENEVA
Middle Name:
Last Name:CHENNAULT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3499 DULUTH PARK LN STE 210
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-5715
Mailing Address - Country:US
Mailing Address - Phone:770-478-6548
Mailing Address - Fax:
Practice Address - Street 1:3499 DULUTH PARK LN STE 210
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5715
Practice Address - Country:US
Practice Address - Phone:770-478-6548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-16
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT004356225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty