Healthcare Provider Details

I. General information

NPI: 1245536622
Provider Name (Legal Business Name): LEA ROSEMARIE THIBEAULT MASSAGE THERIPAST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2011
Last Update Date: 02/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 S CHURCH ST SUITE 115
HAZLETON PA
18201-7605
US

IV. Provider business mailing address

305 S CHURCH ST SUITE 115
HAZLETON PA
18201-7605
US

V. Phone/Fax

Practice location:
  • Phone: 570-497-4766
  • Fax: 570-245-3899
Mailing address:
  • Phone: 570-497-4766
  • Fax: 570-245-3899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: