Provider Demographics
NPI:1922129725
Name:FISHBURN, MARY HELEN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:HELEN
Last Name:FISHBURN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
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Mailing Address - Street 1:720 S LIPSCOMB
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:MO
Mailing Address - Zip Code:65738-2282
Mailing Address - Country:US
Mailing Address - Phone:417-732-9589
Mailing Address - Fax:417-732-9589
Practice Address - Street 1:1887 N HWY CC
Practice Address - Street 2:
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714-8015
Practice Address - Country:US
Practice Address - Phone:417-725-5774
Practice Address - Fax:417-725-5915
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2001003375225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1922129725Other22 MASSAGE THERAPIST