=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285491068
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. GUINEVERE CASSANDRA EATMON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2024
-----------------------------------------------------
Last Update Date | 02/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24781 5 MILE RD # 107
-----------------------------------------------------
City | REDFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48239-3632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-475-4251
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 43422 W OAKS DR # 424
-----------------------------------------------------
City | NOVI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48377-3300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-475-4251
-----------------------------------------------------
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 | 7501014606
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------