Healthcare Provider Details

I. General information

NPI: 1205409265
Provider Name (Legal Business Name): CORINA TYRRELL LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

389 PRESSLER RD
WALLKILL NY
12589-2755
US

IV. Provider business mailing address

389 PRESSLER RD
WALLKILL NY
12589-2755
US

V. Phone/Fax

Practice location:
  • Phone: 925-592-7496
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number18KT01406600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: