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General NPI Number Information
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NPI Number | 1962065813
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Entity Type | Individual
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Provider Name | BETH ANN DENNISTON MT
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Gender | Female
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Dates
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Enumeration Date | 04/16/2019
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Last Update Date | 04/16/2019
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Provider Practice Location Address
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Address Line | 341 S LINCOLN ST APT 4
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City | BLOOMINGTON
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State | IN
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Zip | 47401-2705
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Country | US
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Telephone | 812-369-9910
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Fax |
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Provider Business Mailing Address
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Address Line | 4123 W SIERRA DR
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City | BLOOMINGTON
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State | IN
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Zip | 47403-5138
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Country | US
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Telephone | 812-369-9910
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MT21405186
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License Number State | IN
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