Healthcare Provider Details

I. General information

NPI: 1821768847
Provider Name (Legal Business Name): THAIS DIEHL CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2021
Last Update Date: 09/20/2021
Certification Date: 09/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 5TH ST
BERKELEY CA
94710-1713
US

IV. Provider business mailing address

1530 5TH ST # A
BERKELEY CA
94710-1713
US

V. Phone/Fax

Practice location:
  • Phone: 510-725-1179
  • Fax:
Mailing address:
  • Phone: 510-725-1179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number87690
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: