Healthcare Provider Details

I. General information

NPI: 1194141135
Provider Name (Legal Business Name): KNEAD TO HEAL THERAPEUTIC MASSAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2014
Last Update Date: 03/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 CAYLA LN
PORT JEFFERSON STATION NY
11776-4257
US

IV. Provider business mailing address

8 CAYLA LN
PORT JEFFERSON STATION NY
11776-4257
US

V. Phone/Fax

Practice location:
  • Phone: 631-828-5337
  • Fax:
Mailing address:
  • Phone: 631-828-5337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number013171-1
License Number StateNY

VIII. Authorized Official

Name: MS. DIANNE CAROL SIMONETTI
Title or Position: MASSAGE THERAPIST
Credential: LMT
Phone: 631-828-5337