Provider Demographics
NPI:1578396628
Name:SOISSON, MARY (LMT MTI ATSI)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SOISSON
Suffix:
Gender:F
Credentials:LMT MTI ATSI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 S W S YOUNG DR STE 110
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-3416
Mailing Address - Country:US
Mailing Address - Phone:254-415-7587
Mailing Address - Fax:
Practice Address - Street 1:3010 BUS HWY 14
Practice Address - Street 2:SUITE 112
Practice Address - City:COPPERAS COVE
Practice Address - State:TX
Practice Address - Zip Code:76522
Practice Address - Country:US
Practice Address - Phone:254-238-8558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-23
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT110503225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist