=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679019343
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATELIN BAXA LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2017
-----------------------------------------------------
Last Update Date | 01/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 716 W MARKET ST STE A
-----------------------------------------------------
City | TIFFIN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44883-2582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-443-8877
-----------------------------------------------------
Fax | 419-443-8885
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 716 W MARKET ST STE A
-----------------------------------------------------
City | TIFFIN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44883-2582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-443-8877
-----------------------------------------------------
Fax | 419-443-8885
-----------------------------------------------------
=====================================================
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 | 33.023033
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------