Healthcare Provider Details

I. General information

NPI: 1225505902
Provider Name (Legal Business Name): ANNA TIDWELL MASSAGE THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. ANNA FLETCHER

II. Dates (important events)

Enumeration Date: 10/31/2018
Last Update Date: 10/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6076 LAHRING RD
LINDEN MI
48451-8610
US

IV. Provider business mailing address

6076 LAHRING RD
LINDEN MI
48451-8610
US

V. Phone/Fax

Practice location:
  • Phone: 810-625-6378
  • Fax:
Mailing address:
  • Phone: 810-625-6378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7501005347
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: