Provider Demographics
NPI:1962065813
Name:DENNISTON, BETH ANN (MT)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:ANN
Last Name:DENNISTON
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4123 W SIERRA DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-5138
Mailing Address - Country:US
Mailing Address - Phone:812-369-9910
Mailing Address - Fax:
Practice Address - Street 1:341 S LINCOLN ST APT 4
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-2705
Practice Address - Country:US
Practice Address - Phone:812-369-9910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT21405186225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INMT21405186OtherMASSAGE THERAPY