Healthcare Provider Details

I. General information

NPI: 1679857783
Provider Name (Legal Business Name): ANTISHA BROWN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2011
Last Update Date: 12/11/2019
Certification Date: 12/11/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18640 MACK AVE # 65
GROSSE POINTE FARMS MI
48236-7700
US

IV. Provider business mailing address

25801 HARPER AVE STE 8
SAINT CLAIR SHORES MI
48081-2233
US

V. Phone/Fax

Practice location:
  • Phone: 313-437-1131
  • Fax:
Mailing address:
  • Phone: 313-971-9679
  • Fax: 586-261-5300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: