Provider Demographics
NPI:1619294030
Name:CLARIDGE, MARY MAGDALINE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:MAGDALINE
Last Name:CLARIDGE
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 1:100 TOBIE LN
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-2642
Mailing Address - Country:US
Mailing Address - Phone:606-524-5738
Mailing Address - Fax:
Practice Address - Street 1:649 MEYERS BAKER RD
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-3006
Practice Address - Country:US
Practice Address - Phone:606-878-0011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-25
Last Update Date:2010-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0213225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist