Provider Demographics
NPI:1629824990
Name:SOLACE, JERED DION
Entity type:Individual
Prefix:
First Name:JERED
Middle Name:DION
Last Name:SOLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JERED
Other - Middle Name:DION
Other - Last Name:EHRLICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2160 GLENCOE HILLS DR APT 10
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1022
Mailing Address - Country:US
Mailing Address - Phone:620-757-3327
Mailing Address - Fax:
Practice Address - Street 1:5301 MCAULEY DR
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1051
Practice Address - Country:US
Practice Address - Phone:734-712-5482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-27
Last Update Date:2024-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501015139225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
597133-10OtherNATIONAL CERTIFICATION BOARD OF THERAPEUTIC MASSAGE AND BODYWORK (NCBTMB)