=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366306862
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARTER MARIE CARTER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2025
-----------------------------------------------------
Last Update Date | 12/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2939 WILSON AVE SW # 111
-----------------------------------------------------
City | GRANDVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49418-1271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-547-3065
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2939 WILSON AVE SW # 111
-----------------------------------------------------
City | GRANDVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49418-1271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-547-3065
-----------------------------------------------------
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 | MT105184
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------