Provider Demographics
NPI:1114270808
Name:KOVELESKI, BRENDA LEE (LMT)
Entity type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:LEE
Last Name:KOVELESKI
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 1:414 W MANSION ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-1404
Mailing Address - Country:US
Mailing Address - Phone:517-474-0993
Mailing Address - Fax:269-781-3145
Practice Address - Street 1:414 W MANSION ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-1404
Practice Address - Country:US
Practice Address - Phone:517-474-0993
Practice Address - Fax:269-781-3145
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-18
Last Update Date:2012-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist