Provider Demographics
NPI:1366713562
Name:WAMBEKE, TINA CECILIE
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:CECILIE
Last Name:WAMBEKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 S. MAIN ST.
Mailing Address - Street 2:P.O. BOX 863
Mailing Address - City:THREE FORKS
Mailing Address - State:MT
Mailing Address - Zip Code:59752-0863
Mailing Address - Country:US
Mailing Address - Phone:406-285-4263
Mailing Address - Fax:406-285-4628
Practice Address - Street 1:119 S. MAIN ST.
Practice Address - Street 2:RESTORATION MASSAGE THERAPY, LLC
Practice Address - City:THREE FORKS
Practice Address - State:MT
Practice Address - Zip Code:59752
Practice Address - Country:US
Practice Address - Phone:406-285-4263
Practice Address - Fax:406-285-4628
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1232172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTLICENSE 1232OtherMONTANA BOARD OF MASSAGE THERAPY
MTLICENSE 7956OtherBOARD OF MEDICAL EXAMINERS, EMERGENCY MEDICAL TECHNICIAN- BASIC