Provider Demographics
NPI:1083191399
Name:THRELKELD, MATEEN (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:MATEEN
Middle Name:
Last Name:THRELKELD
Suffix:
Gender:M
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 CANTERBURY DR
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-2337
Mailing Address - Country:US
Mailing Address - Phone:248-904-3132
Mailing Address - Fax:
Practice Address - Street 1:1265 W HURON ST STE 101
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-3677
Practice Address - Country:US
Practice Address - Phone:248-977-4594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PL1743888OtherLIABILITY INSURANCE