Provider Demographics
NPI:1124586375
Name:KIRK, CYNTHIA (LMT)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:KIRK
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 1:317 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:MI
Mailing Address - Zip Code:49220-9529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1539
Practice Address - Country:US
Practice Address - Phone:517-264-1699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501010992225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist