=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447852017
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHYLLIS DOUGLASS CAMTC# 56843
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2020
-----------------------------------------------------
Last Update Date | 11/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 340 S GLENDORA AVE
-----------------------------------------------------
City | GLENDORA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91741-6255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-967-0246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1901 CANOPY LN
-----------------------------------------------------
City | LA VERNE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91750-3514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-967-0246
-----------------------------------------------------
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 | 56843
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------