Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | MT21405241 | IN |
NPI | 1013568708 |
---|---|
Provider Name | Mrs. Alicia Marie Burger |
First Address | Terre Haute, IN 47804-1236 |
Second Address | Terre Haute, IN 47804-1236 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/09/2019 |
Last Update Date | 24/09/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
MT21405241 | LICENSED MASSAGE THERAPIST (01) | IN |