Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 0019009694 | VA |
NPI | 1013391630 |
---|---|
Provider Name | Mary Moore |
First Address | Fredericksburg, VA 22408-9561 |
Second Address | Stafford, VA 22554-7292 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/07/2015 |
Last Update Date | 14/07/2015 |