Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | M05618 | MD |
NPI | 1003262171 |
---|---|
Provider Name | Bernice Burroughs |
First Address | Prince Frederick, MD 20678-3433 |
Second Address | Solomons, MD 20688 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/05/2016 |
Last Update Date | 09/05/2016 |