Provider Demographics
NPI:1295382356
Name:COLSON, TYWANA R (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:TYWANA
Middle Name:R
Last Name:COLSON
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 1:9178 LAKEPOINTE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-2807
Mailing Address - Country:US
Mailing Address - Phone:313-205-6882
Mailing Address - Fax:
Practice Address - Street 1:25511 SOUTHFIELD RD STE 114
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-1830
Practice Address - Country:US
Practice Address - Phone:313-205-6882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501009088225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty