Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | MT2355 | ME |
NPI | 1013329747 |
---|---|
Provider Name | Karissa Beverage |
First Address | Rockland, ME 04841-0651 |
Second Address | Rockland, ME 04841-2928 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/05/2014 |
Last Update Date | 29/05/2014 |