Provider Demographics
NPI:1336591999
Name:MIRAGE THERAPEUTIC TOUCH
Entity Type:Organization
Organization Name:MIRAGE THERAPEUTIC TOUCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LYNNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHALL-SIMS
Authorized Official - Suffix:
Authorized Official - Credentials:BCTMB, LMT
Authorized Official - Phone:248-346-5948
Mailing Address - Street 1:19603 MOENART ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-2309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19603 MOENART ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-2309
Practice Address - Country:US
Practice Address - Phone:248-346-5948
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty