Healthcare Provider Details

I. General information

NPI: 1780917633
Provider Name (Legal Business Name): BONNIE RAE BROWN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2009
Last Update Date: 09/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 N LIMESTONE ST
SPRINGFIELD OH
45503-3609
US

IV. Provider business mailing address

1450 E US HIGHWAY 36
URBANA OH
43078-9112
US

V. Phone/Fax

Practice location:
  • Phone: 937-717-4828
  • Fax: 937-717-6539
Mailing address:
  • Phone: 937-653-7333
  • Fax: 937-652-4574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number014361
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: