Provider Demographics
NPI:1215258264
Name:LEGROS, ERIN BERNICE (MASSAGE THERAPIST)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:BERNICE
Last Name:LEGROS
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 W 39TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-3929
Mailing Address - Country:US
Mailing Address - Phone:317-921-0972
Mailing Address - Fax:
Practice Address - Street 1:740 E 52ND ST
Practice Address - Street 2:SUITE 12
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-1172
Practice Address - Country:US
Practice Address - Phone:317-921-0972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-14
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT20903164173C00000X, 174H00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist
No174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
INMT20903164OtherINDIANA PROFESSIONAL LICENSING AGENCY