Healthcare Provider Details

I. General information

NPI: 1518110568
Provider Name (Legal Business Name): MAUREEN B ROE C.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2008
Last Update Date: 11/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 MERCANTILE ST.
DUBOIS WY
82513-1234
US

IV. Provider business mailing address

PO BOX 1234
DUBOIS WY
82513-1234
US

V. Phone/Fax

Practice location:
  • Phone: 307-455-3504
  • Fax:
Mailing address:
  • Phone: 307-455-3504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: