Provider Demographics
NPI:1336734896
Name:MCCANN, MERCEDES (LMT)
Entity Type:Individual
Prefix:
First Name:MERCEDES
Middle Name:
Last Name:MCCANN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11205
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59719-1205
Mailing Address - Country:US
Mailing Address - Phone:406-579-9420
Mailing Address - Fax:
Practice Address - Street 1:24 S WILLSON AVE
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-4665
Practice Address - Country:US
Practice Address - Phone:406-579-9420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-06
Last Update Date:2021-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LMT-LIC-3994225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTLMT-LMT-LIC-3994OtherSTATE OF MONTANA