Provider Demographics
NPI:1982182739
Name:ADKINS, GARRY AL (BCTMB)
Entity Type:Individual
Prefix:
First Name:GARRY
Middle Name:AL
Last Name:ADKINS
Suffix:
Gender:M
Credentials:BCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29532 SOUTHFIELD RD STE 106
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2023
Mailing Address - Country:US
Mailing Address - Phone:248-701-8306
Mailing Address - Fax:
Practice Address - Street 1:29532 SOUTHFIELD RD STE 106
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2023
Practice Address - Country:US
Practice Address - Phone:248-701-8306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501004693225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7501004693OtherMASSAGE THERAPIST LICENSING