Provider Demographics
NPI:1578803672
Name:SQUIRES, FELICIA (LMT)
Entity Type:Individual
Prefix:
First Name:FELICIA
Middle Name:
Last Name:SQUIRES
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 1:3941 SAINT IVES RD UNIT 911
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-1174
Mailing Address - Country:US
Mailing Address - Phone:518-788-6866
Mailing Address - Fax:
Practice Address - Street 1:3941 SAINT IVES RD UNIT 911
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-1174
Practice Address - Country:US
Practice Address - Phone:518-788-6866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-26
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7097174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7097OtherMASSAGE THERAPY LICENSE