Provider Demographics
NPI:1124205422
Name:MODRALL, CINDY (LMP)
Entity Type:Individual
Prefix:
First Name:CINDY
Middle Name:
Last Name:MODRALL
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:359 MOIESE LANE
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MT
Mailing Address - Zip Code:59870-6223
Mailing Address - Country:US
Mailing Address - Phone:406-361-1337
Mailing Address - Fax:
Practice Address - Street 1:359 MOIESE LANE
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MT
Practice Address - Zip Code:59870-6223
Practice Address - Country:US
Practice Address - Phone:406-361-1337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-29
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022581225700000X
MT4088225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist