Provider Demographics
NPI:1487385233
Name:EIDEMILLER, COLLEEN (LMT)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:EIDEMILLER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:EIDEMILLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:1928 DONN DAVIS WAY
Mailing Address - Street 2:
Mailing Address - City:TIPP CITY
Mailing Address - State:OH
Mailing Address - Zip Code:45371-7313
Mailing Address - Country:US
Mailing Address - Phone:937-266-9756
Mailing Address - Fax:
Practice Address - Street 1:1928 DONN DAVIS WAY
Practice Address - Street 2:
Practice Address - City:TIPP CITY
Practice Address - State:OH
Practice Address - Zip Code:45371-7313
Practice Address - Country:US
Practice Address - Phone:937-266-9756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.018352225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist