Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | MT007946 | TX |
NPI | 1003240383 |
---|---|
Provider Name | Ms. Lyn Childress |
First Address | Odessa, TX 79762-5932 |
Second Address | Odessa, TX 79762-5932 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/08/2013 |
Last Update Date | 27/08/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
MT007946 | BLUE CROSS BLUE SHIELD (01) | TX |