Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | MT124078 | TX |
NPI | 1013574821 |
---|---|
Provider Name | Charlette D Evans |
First Address | Garland, TX 75040-8557 |
Second Address | Garland, TX 75041-3731 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/05/2019 |
Last Update Date | 11/06/2019 |