Provider Demographics
NPI:1538819586
Name:MUNSELL-SIMPSON, ANDREA J (LMT)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:J
Last Name:MUNSELL-SIMPSON
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 1:5415 SILVERTON DR
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-4341
Mailing Address - Country:US
Mailing Address - Phone:810-287-2252
Mailing Address - Fax:
Practice Address - Street 1:17245 SILVER PKWY # 8
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3423
Practice Address - Country:US
Practice Address - Phone:810-287-2252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501008250225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist