MEDICARE: MRS. SANDRA GAYLE CLEVENGER LMT

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	3652	TN

General Provider Information

NPI Number	:	1952442006
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SANDRA GAYLE CLEVENGER LMT

Provider Business Mailing Address
First Line	:	66 LINCOLN LOOP
Second Line	:
City	:	FLINTVILLE
State	:	TN
Zip	:	37335-5330
Country	:	US
Telephone Number	:	931-937-7736
Fax Number	:

Provider Business Practice Location Address
First Line	:	2122 N JACKSON ST
Second Line	:
City	:	TULLAHOMA
State	:	TN
Zip	:	37388-2208
Country	:	US
Telephone Number	:	931-461-5233
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/10/2007
Last Update Date	:	07/08/2007

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