Healthcare Provider Details

I. General information

NPI: 1396948006
Provider Name (Legal Business Name): KAREN BOODJEH LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12016 MORTIMER AVE
CLEVELAND OH
44111-5043
US

IV. Provider business mailing address

6828 HIGHLAND DR
INDEPENDENCE OH
44131-6319
US

V. Phone/Fax

Practice location:
  • Phone: 216-889-1745
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number33.006794
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: