Healthcare Provider Details

I. General information

NPI: 1477759082
Provider Name (Legal Business Name): DIANA ARLENE HARRISON MASSAGE THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 N MAPLE ST
ELDON MO
65026-1761
US

IV. Provider business mailing address

116 N MAPLE ST
ELDON MO
65026-1761
US

V. Phone/Fax

Practice location:
  • Phone: 573-392-8248
  • Fax:
Mailing address:
  • Phone: 573-392-8248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2002026960
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: