=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013104413
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUDITH ANN LITTLE LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2007
-----------------------------------------------------
Last Update Date | 09/28/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5150 BROADWAY
-----------------------------------------------------
City | DEPEW
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14043-4021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-913-8370
-----------------------------------------------------
Fax | 716-681-0232
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29 CHURCH ST
-----------------------------------------------------
City | LANCASTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14086-2603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-681-0232
-----------------------------------------------------
Fax | 716-681-0232
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 008908-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------