Provider Demographics
NPI:1437437621
Name:KNODEN, MARY NAN (LMT,MTICL)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:NAN
Last Name:KNODEN
Suffix:
Gender:F
Credentials:LMT,MTICL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4353 CROW RD STE A
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-7085
Mailing Address - Country:US
Mailing Address - Phone:409-860-9500
Mailing Address - Fax:
Practice Address - Street 1:4353 CROW RD STE A
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-7085
Practice Address - Country:US
Practice Address - Phone:409-860-9500
Practice Address - Fax:409-860-9530
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-22
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist