Healthcare Provider Details

I. General information

NPI: 1619579869
Provider Name (Legal Business Name): ELIZABETH INBODEN LMT, MMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2020
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11218 N 200TH ST
OBLONG IL
62449-2816
US

IV. Provider business mailing address

5192 N 400TH ST
OBLONG IL
62449-3926
US

V. Phone/Fax

Practice location:
  • Phone: 618-553-4391
  • Fax:
Mailing address:
  • Phone: 618-553-4391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227.021861
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: