=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104468495
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY BETH BURRELL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2019
-----------------------------------------------------
Last Update Date | 08/26/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1713 N COLLEGE AVE STE 1
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47404-2479
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-337-3529
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1318 W KIRKWOOD AVE
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47404-5062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-325-2985
-----------------------------------------------------
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 | MT20902125
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------