Provider Demographics
NPI:1013291855
Name:MEMPHIS MYOFASCIAL RELEASE, LLC
Entity Type:Organization
Organization Name:MEMPHIS MYOFASCIAL RELEASE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST & OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEIGH
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:901-435-6045
Mailing Address - Street 1:95 S MAIN ST
Mailing Address - Street 2:#105
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2944
Mailing Address - Country:US
Mailing Address - Phone:901-435-6045
Mailing Address - Fax:901-202-7581
Practice Address - Street 1:95 S MAIN ST
Practice Address - Street 2:#105
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-2944
Practice Address - Country:US
Practice Address - Phone:901-435-6045
Practice Address - Fax:901-202-7581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-28
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2915225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty