Provider Demographics
NPI:1346922879
Name:PRUM, THANIT
Entity Type:Individual
Prefix:
First Name:THANIT
Middle Name:
Last Name:PRUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 ROCKLAND ST # 1
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-7636
Mailing Address - Country:US
Mailing Address - Phone:978-424-6789
Mailing Address - Fax:
Practice Address - Street 1:73 PRINCETON ST STE 212
Practice Address - Street 2:
Practice Address - City:NORTH CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01863-1681
Practice Address - Country:US
Practice Address - Phone:978-424-6789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2295225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist