Basic Information
| Provider Information | |||||||||
| NPI: | 1013118819 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONKLIN | ||||||||
| FirstName: | TAMI | ||||||||
| MiddleName: | SUE | ||||||||
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| Credential: | LMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7053 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436171114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198431370 | ||||||||
| FaxNumber: | 4198438402 | ||||||||
| Practice Location | |||||||||
| Address1: | 7053 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436171114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198431370 | ||||||||
| FaxNumber: | 4198438402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 33.010004 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
ID Information
| ID | Type | State | Issuer | Description | 33.010004 | 01 | OH | LICENSE | OTHER | 1356339857 | 01 | OH | NPI | OTHER |