Healthcare Provider Details

I. General information

NPI: 1215523519
Provider Name (Legal Business Name): ELEMENTS OF HEALTH VA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2020
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 PORTSMOUTH BLVD STE 262
CHESAPEAKE VA
23321-2138
US

IV. Provider business mailing address

4247 WHITE CAP CRST
CHESAPEAKE VA
23321-3256
US

V. Phone/Fax

Practice location:
  • Phone: 757-956-5742
  • Fax: 757-695-9801
Mailing address:
  • Phone: 678-702-7290
  • Fax: 757-695-9801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: SHAWNTE LATRYCE PETERSON
Title or Position: OWNER
Credential: LMT, CHES
Phone: 757-529-1647