Healthcare Provider Details

I. General information

NPI: 1962039107
Provider Name (Legal Business Name): MAUREEN MARSO KSMINSKI LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 03/26/2020
Certification Date: 03/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 N MOUNTAIN BLVD
MOUNTAIN TOP PA
18707-1117
US

IV. Provider business mailing address

352 ALBERDEEN RD
MOUNTAIN TOP PA
18707-9471
US

V. Phone/Fax

Practice location:
  • Phone: 570-371-9089
  • Fax:
Mailing address:
  • Phone: 570-574-5106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMSG010413
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: