Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 3078 | SC |
NPI | 1013536432 |
---|---|
Provider Name | Wanda Ruby Godley |
First Address | Ladys Island, SC 29907-1460 |
Second Address | Ladys Island, SC 29907-1460 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/04/2020 |
Last Update Date | 15/04/2020 |