Healthcare Provider Details

I. General information

NPI: 1558832246
Provider Name (Legal Business Name): TIANA FREEMAN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2018
Last Update Date: 12/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5940 GOODWIN AVE UNIT D
JBER AK
99506-3539
US

IV. Provider business mailing address

5940 GOODWIN AVE UNIT D
JBER AK
99506-3539
US

V. Phone/Fax

Practice location:
  • Phone: 715-415-1925
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number133096
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: