Healthcare Provider Details

I. General information

NPI: 1306627203
Provider Name (Legal Business Name): THEODORA FIOTODIMITRAKIS LMT, CHHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2023
Last Update Date: 10/09/2023
Certification Date: 10/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2178 21ST ST
ASTORIA NY
11105-3618
US

IV. Provider business mailing address

2112 DITMARS BLVD
ASTORIA NY
11105-3417
US

V. Phone/Fax

Practice location:
  • Phone: 646-504-2112
  • Fax:
Mailing address:
  • Phone: 646-359-2498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number033056
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: