=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457618142
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUMMER CORRIE LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2012
-----------------------------------------------------
Last Update Date | 04/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 291 WALL ST SUITE 2A
-----------------------------------------------------
City | KINGSTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12401-3849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-633-0099
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3011 ROUTE 44 55 APT 9
-----------------------------------------------------
City | GARDINER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12525-5053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-633-0099
-----------------------------------------------------
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 | 020208-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------