Provider Demographics
NPI:1588951610
Name:PAUL, CHEVONNE (LMT, CMT, MMP)
Entity type:Individual
Prefix:MS
First Name:CHEVONNE
Middle Name:
Last Name:PAUL
Suffix:
Gender:F
Credentials:LMT, CMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 853
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MD
Mailing Address - Zip Code:20763-0853
Mailing Address - Country:US
Mailing Address - Phone:240-547-9144
Mailing Address - Fax:240-599-9144
Practice Address - Street 1:345 MAIN ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-7116
Practice Address - Country:US
Practice Address - Phone:240-547-9144
Practice Address - Fax:240-599-9144
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-11
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM04080225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist