=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720596224
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLEEN FEWTRELL LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2018
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8089 STADIUM DR # DT
-----------------------------------------------------
City | KALAMAZOO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49009-6270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-888-3608
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 65578 PARKWOOD CT
-----------------------------------------------------
City | PAW PAW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49079-9779
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-380-6280
-----------------------------------------------------
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 | 7501007887
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------