Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | M05380 | MD |
NPI | 1003275785 |
---|---|
Provider Name | Mr. Kenneth Washington |
First Address | Elkridge, MD 21075-5987 |
Second Address | Elkridge, MD 21075-5412 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/02/2016 |
Last Update Date | 23/02/2016 |