Provider Demographics
NPI:1710251566
Name:PROUGH, CYNTHIA (NCMTB)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:PROUGH
Suffix:
Gender:F
Credentials:NCMTB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11501 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:MI
Mailing Address - Zip Code:49269-9333
Mailing Address - Country:US
Mailing Address - Phone:517-917-6012
Mailing Address - Fax:
Practice Address - Street 1:205 17TH ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-1403
Practice Address - Country:US
Practice Address - Phone:517-917-6012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-25
Last Update Date:2012-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI597534-10225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist