Provider Demographics
NPI:1235594078
Name:WERSTINE, MARYELLEN (LMT)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:
Last Name:WERSTINE
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 1:11954 WOODVIEW TRL
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-8097
Mailing Address - Country:US
Mailing Address - Phone:989-280-8683
Mailing Address - Fax:
Practice Address - Street 1:4670 LAKESHORE RD
Practice Address - Street 2:
Practice Address - City:BOYNE CITY
Practice Address - State:MI
Practice Address - Zip Code:49712-9757
Practice Address - Country:US
Practice Address - Phone:885-999-9287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501004691225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist