Provider Demographics
NPI:1821457102
Name:PHRAKOUSONH, DIANA (LMT- LICENSE MASSAGE)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:PHRAKOUSONH
Suffix:
Gender:F
Credentials:LMT- LICENSE MASSAGE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26250 EUCLID AVE.
Mailing Address - Street 2:SUITE 711
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44132
Mailing Address - Country:US
Mailing Address - Phone:216-261-7715
Mailing Address - Fax:216-261-7746
Practice Address - Street 1:26250 EUCLID AVE.
Practice Address - Street 2:SUITE 711
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44132
Practice Address - Country:US
Practice Address - Phone:216-261-7715
Practice Address - Fax:216-261-7746
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-16
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.016805225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist