=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144862665
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TONIANN IVAIN LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2019
-----------------------------------------------------
Last Update Date | 01/26/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 81 MAIN ST
-----------------------------------------------------
City | SHARON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06069-2018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-456-5631
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 259 SHARON RD
-----------------------------------------------------
City | MILLERTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12546-5217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-456-5631
-----------------------------------------------------
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 | 10608
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------