Healthcare Provider Details

I. General information

NPI: 1346617834
Provider Name (Legal Business Name): AMY WEIGOLD, LMT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2015
Last Update Date: 08/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1532 CERRILLOS RD
SANTA FE NM
87505-3512
US

IV. Provider business mailing address

3005 S SAINT FRANCIS DR SUITE 1-D, UNIT 439
SANTA FE NM
87505-6964
US

V. Phone/Fax

Practice location:
  • Phone: 318-510-7840
  • Fax:
Mailing address:
  • Phone: 318-510-7840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7934
License Number StateNM

VIII. Authorized Official

Name: MS. AMY ELIZABETH WEIGOLD
Title or Position: LICENSED MASSAGE THERAPIST
Credential: LMT
Phone: 318-510-7840