Provider Demographics
NPI:1790180396
Name:THERAPEUTIC MASSAGE REHABILITATION
Entity Type:Organization
Organization Name:THERAPEUTIC MASSAGE REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:KEAVENY
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:248-320-1310
Mailing Address - Street 1:1759 ASHSTAN DR
Mailing Address - Street 2:
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-2612
Mailing Address - Country:US
Mailing Address - Phone:248-320-1310
Mailing Address - Fax:
Practice Address - Street 1:800 N MILFORD RD STE 600
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-1599
Practice Address - Country:US
Practice Address - Phone:248-320-1310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501003479261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation