Healthcare Provider Details

I. General information

NPI: 1780358887
Provider Name (Legal Business Name): PAUL SEPP-GUMBERT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2021
Last Update Date: 08/03/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 E MAIN ST
BOONVILLE IN
47601-1649
US

IV. Provider business mailing address

116 E MAIN ST
BOONVILLE IN
47601-1649
US

V. Phone/Fax

Practice location:
  • Phone: 812-660-2270
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT21906870
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: