Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | MT134202 | TX |
NPI | 1003571084 |
---|---|
Provider Name | Nina Grace Roloff |
First Address | Fort Worth, TX 76137-4123 |
Second Address | Fort Worth, TX 76137-4123 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/11/2021 |
Last Update Date | 03/11/2021 |