Provider Demographics
NPI:1689079659
Name:BARD, MARJORIE LEE (LMT)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:LEE
Last Name:BARD
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 1:2208 W WILLOW KNOLLS RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-1467
Mailing Address - Country:US
Mailing Address - Phone:309-693-9600
Mailing Address - Fax:309-693-3616
Practice Address - Street 1:2208 W WILLOW KNOLLS RD.
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-1467
Practice Address - Country:US
Practice Address - Phone:309-693-9600
Practice Address - Fax:309-693-3616
Is Sole Proprietor?:No
Enumeration Date:2014-11-03
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227010716225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist