MEDICARE: DEANNA'S THERAPEUTIC MASSAGE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	7501000594	MI

General Provider Information

NPI Number	:	1841680188
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEANNA'S THERAPEUTIC MASSAGE LLC

Provider Business Mailing Address
First Line	:	7938 COOLEY LAKE RD
Second Line	:	SUITE 400W
City	:	WATERFORD
State	:	MI
Zip	:	48327-4404
Country	:	US
Telephone Number	:	248-345-6475
Fax Number	:

Provider Business Practice Location Address
First Line	:	7938 COOLEY LAKE RD
Second Line	:	SUITE 400W
City	:	WATERFORD
State	:	MI
Zip	:	48327-4404
Country	:	US
Telephone Number	:	248-345-6475
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DEANNA GOODWIN
Credential	:	C.M.T.
Telephone Number	:	248-345-6475

Provider Enumeration Date	:	01/26/2015
Last Update Date	:	01/26/2015

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