Provider Demographics
NPI:1154128742
Name:PRATHER, MIA (LMT)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:PRATHER
Suffix:
Gender:
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 W ANIMAS ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-5617
Mailing Address - Country:US
Mailing Address - Phone:505-330-4176
Mailing Address - Fax:855-263-7200
Practice Address - Street 1:724 W ANIMAS ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5617
Practice Address - Country:US
Practice Address - Phone:505-793-1760
Practice Address - Fax:855-263-7200
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-28
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMT-2025-0008225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist