Healthcare Provider Details

I. General information

NPI: 1356273379
Provider Name (Legal Business Name): SOUTHERN SELECT MASSAGE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1433 OLD HAMOND HWY , 302B
BATON ROUGE LA
70816
US

IV. Provider business mailing address

12518 WYNDY AVE
BATON ROUGE LA
70816-4759
US

V. Phone/Fax

Practice location:
  • Phone: 225-272-1401
  • Fax:
Mailing address:
  • Phone: 225-448-4499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. TREY JOSEPH IVERSTINE
Title or Position: PRESIDENT
Credential: LMT
Phone: 225-448-4499