=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649821869
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AUDRA DORSEY LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2019
-----------------------------------------------------
Last Update Date | 09/28/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24300 CHAGRIN BLVD STE 312
-----------------------------------------------------
City | BEACHWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44122-5629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-704-7848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27720 TUNGSTEN ROAD #63
-----------------------------------------------------
City | EUCLID
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-704-7848
-----------------------------------------------------
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 | 33.024726
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------