Provider Demographics
NPI:1114238748
Name:MERRIAM, MINERVA C (MASSAGES THERAPIST)
Entity Type:Individual
Prefix:MS
First Name:MINERVA
Middle Name:C
Last Name:MERRIAM
Suffix:
Gender:F
Credentials:MASSAGES THERAPIST
Other - Prefix:MS
Other - First Name:MINNIE
Other - Middle Name:C
Other - Last Name:MERRIAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:12635 N LA MONTANA DR APT 11
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85268-4537
Mailing Address - Country:US
Mailing Address - Phone:840-390-7404
Mailing Address - Fax:
Practice Address - Street 1:12635 N LA MONTANA DR APT 11
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-4537
Practice Address - Country:US
Practice Address - Phone:840-390-7404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ225700000X225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist