Provider Demographics
NPI:1447995394
Name:HARDY, EFFIE (CMT, CLT)
Entity type:Individual
Prefix:
First Name:EFFIE
Middle Name:
Last Name:HARDY
Suffix:
Gender:F
Credentials:CMT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2616 PACIFIC AVE UNIT 4825
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-7026
Mailing Address - Country:US
Mailing Address - Phone:209-279-6322
Mailing Address - Fax:
Practice Address - Street 1:2009 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5327
Practice Address - Country:US
Practice Address - Phone:209-279-6322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-04
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39185225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist