Provider Demographics
NPI:1619782802
Name:GRACEN, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:GRACEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DREW
Other - Middle Name:
Other - Last Name:GRACEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5480 WILLOW POINT PKWY
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-1834
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3133 MAPLE DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-2505
Practice Address - Country:US
Practice Address - Phone:404-220-7720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-12
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007120225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist