=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154267409
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. WITHERS REA LEE V
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2026
-----------------------------------------------------
Last Update Date | 04/28/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7349 HONEYSUCKLE STE 120
-----------------------------------------------------
City | TEMPLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76502-5888
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-780-6344
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 708 WAGON WHEEL
-----------------------------------------------------
City | HARKER HEIGHTS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76548-2436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-542-7441
-----------------------------------------------------
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 | MT141703
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------