Healthcare Provider Details

I. General information

NPI: 1114836871
Provider Name (Legal Business Name): MICHAEL THOMAS LMBT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2026
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 TYVOLA RD STE 203
CHARLOTTE NC
28217-3649
US

IV. Provider business mailing address

820 TYVOLA RD STE 203
CHARLOTTE NC
28217-3649
US

V. Phone/Fax

Practice location:
  • Phone: 980-292-1090
  • Fax:
Mailing address:
  • Phone: 980-292-1090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number23302
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: