Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 18KT00303400 | NJ |
NPI | 1013423938 |
---|---|
Provider Name | Amy Lou Rodriguez |
First Address | Franklinville, NJ 08322-2041 |
Second Address | Franklinville, NJ 08322-2041 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/12/2017 |
Last Update Date | 16/06/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0 | MASSAGE THERAPIST (01) | |
115854 | AMTA (01) | |
303588-00 | BCTMB (01) |