Provider Demographics
NPI:1740597582
Name:JANECEK, THERESA ELAINE (BA, CMT)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:ELAINE
Last Name:JANECEK
Suffix:
Gender:F
Credentials:BA, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2606 N. PATTERSON BLVD.
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004
Mailing Address - Country:US
Mailing Address - Phone:928-779-5515
Mailing Address - Fax:928-527-0812
Practice Address - Street 1:2606 N. PATTERSON BLVD.
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004
Practice Address - Country:US
Practice Address - Phone:928-779-5515
Practice Address - Fax:928-527-0812
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-05237 STATE OF AZ225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist