Provider Demographics
NPI:1912323320
Name:DANIELS, GENA M (LMT)
Entity type:Individual
Prefix:
First Name:GENA
Middle Name:M
Last Name:DANIELS
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 1:8731 MASON RD
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MI
Mailing Address - Zip Code:48097-1012
Mailing Address - Country:US
Mailing Address - Phone:810-333-5591
Mailing Address - Fax:810-387-9561
Practice Address - Street 1:3085 MAIN ST
Practice Address - Street 2:
Practice Address - City:MARLETTE
Practice Address - State:MI
Practice Address - Zip Code:48453-1243
Practice Address - Country:US
Practice Address - Phone:989-635-3828
Practice Address - Fax:810-387-9561
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-10
Last Update Date:2016-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501001611225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist