=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407034580
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BEVERLY GARRISON RMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2008
-----------------------------------------------------
Last Update Date | 01/31/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1793 MAIN ST
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38671-1214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-603-5959
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 279 LOVE RD
-----------------------------------------------------
City | HERNANDO
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38632-8806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-603-5959
-----------------------------------------------------
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 | RMT868
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------