Healthcare Provider Details

I. General information

NPI: 1093093601
Provider Name (Legal Business Name): ANNETTE ECCLES NCTMBW, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2011
Last Update Date: 01/08/2021
Certification Date: 01/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4229 LAFAYETTE CENTER DR STE 1900
CHANTILLY VA
20151-1260
US

IV. Provider business mailing address

23510 SPINNING WHEEL CT
ALDIE VA
20105-2488
US

V. Phone/Fax

Practice location:
  • Phone: 571-373-2042
  • Fax:
Mailing address:
  • Phone: 571-373-2042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0019009023
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: