Healthcare Provider Details

I. General information

NPI: 1033667837
Provider Name (Legal Business Name): TABITHA RENEE BOAN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 09/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 BUSH LN
DALZELL SC
29040-9724
US

IV. Provider business mailing address

3150 BUSH LN
DALZELL SC
29040-9724
US

V. Phone/Fax

Practice location:
  • Phone: 540-589-4248
  • Fax:
Mailing address:
  • Phone: 540-589-4248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number8291
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: