Healthcare Provider Details

I. General information

NPI: 1144772971
Provider Name (Legal Business Name): SUMERLEE SHADE WOODARD LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 10/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 STATE ROUTE 44
ATWATER OH
44201-9267
US

IV. Provider business mailing address

1485 STATE ROUTE 44
ATWATER OH
44201-9267
US

V. Phone/Fax

Practice location:
  • Phone: 330-325-7390
  • Fax:
Mailing address:
  • Phone: 330-325-7390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number33.022554
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: