Provider Demographics
NPI:1811056195
Name:GARRISON, MARY IRENE (LMT)
Entity type:Individual
Prefix:MISS
First Name:MARY
Middle Name:IRENE
Last Name:GARRISON
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 1:960 ST RT 72 SOUTH
Mailing Address - Street 2:
Mailing Address - City:SABINA
Mailing Address - State:OH
Mailing Address - Zip Code:45169
Mailing Address - Country:US
Mailing Address - Phone:937-302-6911
Mailing Address - Fax:
Practice Address - Street 1:960 ST RT 72 SOUTH
Practice Address - Street 2:
Practice Address - City:SABINA
Practice Address - State:OH
Practice Address - Zip Code:45169
Practice Address - Country:US
Practice Address - Phone:937-302-6911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3313387225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000487064OtherANTHEM BLUE CROSS
OH20492745200OtherW C