Provider Demographics
NPI:1487898581
Name:SERVATIUS, VERONICA (CMT)
Entity type:Individual
Prefix:
First Name:VERONICA
Middle Name:
Last Name:SERVATIUS
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3283 E ANEMONE CT
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-6848
Mailing Address - Country:US
Mailing Address - Phone:208-949-9964
Mailing Address - Fax:
Practice Address - Street 1:3283 E ANEMONE CT
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83716-6848
Practice Address - Country:US
Practice Address - Phone:208-949-9964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMA 090024225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist