=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609193010
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEANNA KAY CRESAP LMT, CMTPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2010
-----------------------------------------------------
Last Update Date | 02/18/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22135 AURORA BOREALIS RD
-----------------------------------------------------
City | CHUGIAK
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99567-6163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-229-9935
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22135 AURORA BOREALIS RD
-----------------------------------------------------
City | CHUGIAK
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99567-6163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-229-9935
-----------------------------------------------------
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 | 922585
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 952071
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------