Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 7501007455 | MI |
NPI | 1003417247 |
---|---|
Provider Name | Melissa Whitaker |
First Address | Riverview, MI 48193-6630 |
Second Address | Riverview, MI 48193-6630 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/11/2020 |
Last Update Date | 04/11/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
7501007455 | LICENSED MASSAGE THERAPIST (01) | MI |