Healthcare Provider Details

I. General information

NPI: 1326746173
Provider Name (Legal Business Name): MARTY K SYRSTAD MASSAGE THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARTY K SULLIVAN MASSAGE THERAPIST

II. Dates (important events)

Enumeration Date: 02/21/2023
Last Update Date: 02/21/2023
Certification Date: 02/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 22ND AVE S
BROOKINGS SD
57006-2803
US

IV. Provider business mailing address

1040 22ND AVE S
BROOKINGS SD
57006-2803
US

V. Phone/Fax

Practice location:
  • Phone: 605-695-2290
  • Fax:
Mailing address:
  • Phone: 605-695-2290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT-10278
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: