Provider Demographics
NPI:1952442006
Name:CLEVENGER, SANDRA GAYLE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:GAYLE
Last Name:CLEVENGER
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 1:66 LINCOLN LOOP
Mailing Address - Street 2:
Mailing Address - City:FLINTVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37335-5330
Mailing Address - Country:US
Mailing Address - Phone:931-937-7736
Mailing Address - Fax:
Practice Address - Street 1:2122 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2208
Practice Address - Country:US
Practice Address - Phone:931-461-5233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3652225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist