Healthcare Provider Details

I. General information

NPI: 1114560158
Provider Name (Legal Business Name): LAURA TOMS LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAURA GOSNELL

II. Dates (important events)

Enumeration Date: 10/22/2019
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5529 N RHETT AVE
NORTH CHARLESTON SC
29406-3507
US

IV. Provider business mailing address

5715 ROBINSON ST
HANAHAN SC
29410-3144
US

V. Phone/Fax

Practice location:
  • Phone: 843-256-3448
  • Fax:
Mailing address:
  • Phone: 301-473-0239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number11784
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: