Provider Demographics
NPI:1063842888
Name:BISHOP, RAELENE ANN (LMT)
Entity Type:Individual
Prefix:MS
First Name:RAELENE
Middle Name:ANN
Last Name:BISHOP
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:671 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5596
Mailing Address - Country:US
Mailing Address - Phone:208-552-2584
Mailing Address - Fax:208-529-3992
Practice Address - Street 1:671 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-5596
Practice Address - Country:US
Practice Address - Phone:208-552-2584
Practice Address - Fax:208-529-3992
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-14
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-1672225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist