Provider Demographics
NPI:1144837832
Name:BROD, RAESHELL (LMT)
Entity type:Individual
Prefix:
First Name:RAESHELL
Middle Name:
Last Name:BROD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:RAESHELL
Other - Middle Name:
Other - Last Name:KENDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:1523 RUNAWAY BAY DR APT 2C
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-4810
Mailing Address - Country:US
Mailing Address - Phone:614-843-4917
Mailing Address - Fax:
Practice Address - Street 1:1523 RUNAWAY BAY DR APT 2C
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-4810
Practice Address - Country:US
Practice Address - Phone:614-843-4917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-26
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33-024982225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH33-024982OtherSTATE MEDICAL BOARD