=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023715133
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALLISON E DESROSIERS LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2023
-----------------------------------------------------
Last Update Date | 02/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1402 S JENTILLY LN UNIT 101
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85281-5716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-742-8997
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1402 S JENTILLY LN UNIT 101
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85281-5716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-742-8997
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | MT-17479
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------