=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104397355
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARRIE LYN ENDEMANN MASSAGE THERAPIST
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2018
-----------------------------------------------------
Last Update Date | 12/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 181 KENWOOD AVE
-----------------------------------------------------
City | ONEIDA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13421-2829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-569-6579
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 214 DRIFTWOOD DR
-----------------------------------------------------
City | ONEIDA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13421-1848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-750-0555
-----------------------------------------------------
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 | 018594
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------