Healthcare Provider Details

I. General information

NPI: 1255651709
Provider Name (Legal Business Name): HOLLY DIANE GUMZ LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2010
Last Update Date: 06/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 14TH ST S
WISCONSIN RAPIDS WI
54494-4911
US

IV. Provider business mailing address

611 14TH ST S
WISCONSIN RAPIDS WI
54494-4911
US

V. Phone/Fax

Practice location:
  • Phone: 715-323-3167
  • Fax:
Mailing address:
  • Phone: 715-323-3167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number4354-046
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: