Healthcare Provider Details

I. General information

NPI: 1831570167
Provider Name (Legal Business Name): CAROLYN MICHELLE ADELAIDE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 07/18/2026
Certification Date: 07/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 S GARDENIA AVE
BROKEN ARROW OK
74012-9041
US

IV. Provider business mailing address

1905 S GARDENIA AVE
BROKEN ARROW OK
74012-9041
US

V. Phone/Fax

Practice location:
  • Phone: 918-891-1373
  • Fax: 918-891-1373
Mailing address:
  • Phone: 918-891-1373
  • Fax: 918-891-1373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7501004307
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: