Provider Demographics
NPI:1003171588
Name:THACKER, CHERYL M (LICENSED MASSAGE THE)
Entity Type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:M
Last Name:THACKER
Suffix:
Gender:F
Credentials:LICENSED MASSAGE THE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1914 MARY ST.
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BCH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-1988
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:531 ATLANTIC BOULEVARD
Practice Address - Street 2:STE 7
Practice Address - City:ATLANTIC BEACH
Practice Address - State:FL
Practice Address - Zip Code:32233
Practice Address - Country:US
Practice Address - Phone:904-305-4723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA25185225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist