Provider Demographics
NPI:1184860256
Name:SMITH, SANDRA P (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:P
Last Name:SMITH
Suffix:
Gender:F
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:P.O. BOX 264
Mailing Address - Street 2:20079 WEST MAIN STREET SUITE B
Mailing Address - City:LANNON
Mailing Address - State:WI
Mailing Address - Zip Code:53046
Mailing Address - Country:US
Mailing Address - Phone:262-502-4051
Mailing Address - Fax:262-502-4053
Practice Address - Street 1:20079 WEST MAIN STREET
Practice Address - Street 2:SUITE B
Practice Address - City:LANNON
Practice Address - State:WI
Practice Address - Zip Code:53046
Practice Address - Country:US
Practice Address - Phone:262-502-4051
Practice Address - Fax:262-502-4053
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-19
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI731-046225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist