Healthcare Provider Details

I. General information

NPI: 1255385647
Provider Name (Legal Business Name): VICKY BEVERIDGE MASSAGE THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

369 NILES CORTLAND RD SE
WARREN OH
44484-2430
US

IV. Provider business mailing address

369 NILES CORTLAND RD SE
WARREN OH
44484-2430
US

V. Phone/Fax

Practice location:
  • Phone: 330-856-3577
  • Fax: 330-856-1094
Mailing address:
  • Phone: 330-856-3577
  • Fax: 330-856-1094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number33.012773
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: