Healthcare Provider Details

I. General information

NPI: 1477272474
Provider Name (Legal Business Name): MICHELLE WREN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2022
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 2ND AVE
GALLIPOLIS OH
45631-1637
US

IV. Provider business mailing address

990 2ND AVE
GALLIPOLIS OH
45631-1637
US

V. Phone/Fax

Practice location:
  • Phone: 740-441-0200
  • Fax: 740-441-1907
Mailing address:
  • Phone: 740-441-0200
  • Fax: 740-441-1907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2011-2882
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number33.025954
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: