Healthcare Provider Details

I. General information

NPI: 1942610613
Provider Name (Legal Business Name): MASSAGE BY MARA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2014
Last Update Date: 05/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3728 PARK AVE
WANTAGH NY
11793-3707
US

IV. Provider business mailing address

3728 PARK AVE
WANTAGH NY
11793-3707
US

V. Phone/Fax

Practice location:
  • Phone: 516-697-7109
  • Fax: 516-679-2684
Mailing address:
  • Phone: 516-697-7109
  • Fax: 516-679-2684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number005235
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number014196
License Number StateNY

VIII. Authorized Official

Name: MS. MARA JENNIFER BERKOWITZ
Title or Position: OWNER
Credential:
Phone: 516-697-7109