Healthcare Provider Details

I. General information

NPI: 1689826422
Provider Name (Legal Business Name): SUSAN FLORENCE MIX LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2008
Last Update Date: 10/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 MAIN ST
STURBRIDGE MA
01566-1284
US

IV. Provider business mailing address

48 MAIN ST
STURBRIDGE MA
01566-1284
US

V. Phone/Fax

Practice location:
  • Phone: 508-612-5545
  • Fax: 508-347-7576
Mailing address:
  • Phone: 508-612-5545
  • Fax: 508-347-7576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number3703
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: