Provider Demographics
NPI:1043346372
Name:MASSIE, JOHN E (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:MASSIE
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 E. GRAND AVE.
Mailing Address - Street 2:SIUC STUDENT HEALTH CENTER
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:374 E. GRAND AVE.
Practice Address - Street 2:SIUC STUDENT HEALTH CENTER
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901
Practice Address - Country:US
Practice Address - Phone:618-453-1292
Practice Address - Fax:618-453-4290
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer