Provider Demographics
NPI:1326746173
Name:SYRSTAD, MARTY K (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:MS
First Name:MARTY
Middle Name:K
Last Name:SYRSTAD
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:MRS
Other - First Name:MARTY
Other - Middle Name:K
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MASSAGE THERAPIST
Mailing Address - Street 1:1040 22ND AVE S
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-2803
Mailing Address - Country:US
Mailing Address - Phone:605-695-2290
Mailing Address - Fax:
Practice Address - Street 1:1040 22ND AVE S
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-2803
Practice Address - Country:US
Practice Address - Phone:605-695-2290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDMT-10278225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist