MEDICARE: EFFIE HARDY CMT, CLT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	39185	CA

General Provider Information

NPI Number	:	1447995394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EFFIE HARDY CMT, CLT

Provider Business Mailing Address
First Line	:	2616 PACIFIC AVE UNIT 4825
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95204-7026
Country	:	US
Telephone Number	:	209-279-6322
Fax Number	:

Provider Business Practice Location Address
First Line	:	2009 PACIFIC AVE
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95204-5327
Country	:	US
Telephone Number	:	209-279-6322
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2022
Last Update Date	:	05/04/2022

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