Healthcare Provider Details

I. General information

NPI: 1275453813
Provider Name (Legal Business Name): KACIE MARIE FARRELL LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 MONTAUK HWY STE 114
MORICHES NY
11955-1411
US

IV. Provider business mailing address

116 SHINNECOCK AVE
MASTIC NY
11950-4230
US

V. Phone/Fax

Practice location:
  • Phone: 631-874-4114
  • Fax: 631-874-4844
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number03192501
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: