Provider Demographics
NPI:1912515974
Name:CCM MASSAGE THERAPY,LLC
Entity Type:Organization
Organization Name:CCM MASSAGE THERAPY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GERLING-LMT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-684-9466
Mailing Address - Street 1:PO BOX 878
Mailing Address - Street 2:
Mailing Address - City:TWIN LAKES
Mailing Address - State:WI
Mailing Address - Zip Code:53181-0878
Mailing Address - Country:US
Mailing Address - Phone:262-684-9466
Mailing Address - Fax:262-279-2214
Practice Address - Street 1:606 COUNTRY LN
Practice Address - Street 2:
Practice Address - City:TWIN LAKES
Practice Address - State:WI
Practice Address - Zip Code:53181-9502
Practice Address - Country:US
Practice Address - Phone:262-684-9466
Practice Address - Fax:262-279-2214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-16
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1720647803Medicaid
WI1912515974Medicaid