Provider Demographics
NPI:1922114719
Name:ETSEN, MARY E (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:ETSEN
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 BIMINI CIR
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-6921
Mailing Address - Country:US
Mailing Address - Phone:772-388-4762
Mailing Address - Fax:772-589-0532
Practice Address - Street 1:2140 10TH AVE
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-5377
Practice Address - Country:US
Practice Address - Phone:772-532-6735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 37226225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist