Healthcare Provider Details

I. General information

NPI: 1881719201
Provider Name (Legal Business Name): CHRIS L WIDLUND LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 10/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 CARMICHAEL ST STE 204
ESSEX JUNCTION VT
05452-3186
US

IV. Provider business mailing address

21 CARMICHAEL ST STE 204
ESSEX JUNCTION VT
05452-3186
US

V. Phone/Fax

Practice location:
  • Phone: 802-233-0600
  • Fax:
Mailing address:
  • Phone: 802-233-0600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00017639
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: