Provider Demographics
NPI:1912479809
Name:EDRIDGE, LORI (MASSAGE THERAPY)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:EDRIDGE
Suffix:
Gender:F
Credentials:MASSAGE THERAPY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9350 STATE HIGHWAY 7 E
Mailing Address - Street 2:
Mailing Address - City:JOAQUIN
Mailing Address - State:TX
Mailing Address - Zip Code:75954-4083
Mailing Address - Country:US
Mailing Address - Phone:903-754-7363
Mailing Address - Fax:
Practice Address - Street 1:9350 STATE HIGHWAY 7 E
Practice Address - Street 2:
Practice Address - City:JOAQUIN
Practice Address - State:TX
Practice Address - Zip Code:75954-4083
Practice Address - Country:US
Practice Address - Phone:903-754-7363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109626225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist