Provider Demographics
NPI:1023345501
Name:RICH, DESARAY LEIGH (LMT)
Entity type:Individual
Prefix:
First Name:DESARAY
Middle Name:LEIGH
Last Name:RICH
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 1:15260 HIGHWAY 105 W # 125
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77356-5259
Mailing Address - Country:US
Mailing Address - Phone:936-570-6060
Mailing Address - Fax:
Practice Address - Street 1:15260 HIGHWAY 105 W # 125
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77356-5259
Practice Address - Country:US
Practice Address - Phone:936-570-6060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT106424225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist