Healthcare Provider Details

I. General information

NPI: 1821457102
Provider Name (Legal Business Name): DIANA PHRAKOUSONH LMT- LICENSE MASSAGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2016
Last Update Date: 02/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26250 EUCLID AVE. SUITE 711
EUCLID OH
44132
US

IV. Provider business mailing address

26250 EUCLID AVE. SUITE 711
EUCLID OH
44132
US

V. Phone/Fax

Practice location:
  • Phone: 216-261-7715
  • Fax: 216-261-7746
Mailing address:
  • Phone: 216-261-7715
  • Fax: 216-261-7746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number33.016805
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: