Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 25010 | CA |
NPI | 1013564368 |
---|---|
Provider Name | Kriscynthia Outlaw |
First Address | Long Beach, CA 90803-4208 |
Second Address | Long Beach, CA 90803-4208 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/08/2019 |
Last Update Date | 21/08/2019 |