=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225706120
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EQUILIBRIUM MASSAGE THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2021
-----------------------------------------------------
Last Update Date | 01/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2224 W HONEYSUCKLE AVE
-----------------------------------------------------
City | HAYDEN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83835-8057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-920-1630
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2226
-----------------------------------------------------
City | HAYDEN LAKE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83835-2226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-215-4594
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MISTY CONNELLA
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 208-920-1630
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------