Healthcare Provider Details

I. General information

NPI: 1922491125
Provider Name (Legal Business Name): BODY BALANCE MASSAGE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2015
Last Update Date: 03/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 7TH AVE SUITE 606
NEW YORK NY
10019-5230
US

IV. Provider business mailing address

1822 ASTORIA PARK S 2ND FLOOR
ASTORIA NY
11102-3444
US

V. Phone/Fax

Practice location:
  • Phone: 718-683-1905
  • Fax:
Mailing address:
  • Phone: 718-683-1905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number27018013
License Number StateNY

VIII. Authorized Official

Name: MISS NICOLE MARIE KENNELLY
Title or Position: OWNER
Credential: LMT
Phone: 718-683-1905