Provider Demographics
NPI:1689861114
Name:BODYWORKS THERAPEUTICS, LLC
Entity Type:Organization
Organization Name:BODYWORKS THERAPEUTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:YVONNE
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:LMT, CMT, CBIS
Authorized Official - Phone:248-798-1657
Mailing Address - Street 1:28611 LATHRUP BLVD
Mailing Address - Street 2:
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2849
Mailing Address - Country:US
Mailing Address - Phone:248-798-1657
Mailing Address - Fax:
Practice Address - Street 1:31815 SOUTHFIELD RD
Practice Address - Street 2:SUITE 16
Practice Address - City:BEVERLY HILLS
Practice Address - State:MI
Practice Address - Zip Code:48025-5471
Practice Address - Country:US
Practice Address - Phone:248-788-6059
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBUS200600893302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization