Healthcare Provider Details

I. General information

NPI: 1619258746
Provider Name (Legal Business Name): MS. LAURETTA A THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2011
Last Update Date: 09/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8550 ARLINGTON BLVD SUITE 325 ROSELLE CENTER FOR HEALING
FAIRFAX VA
22031
US

IV. Provider business mailing address

8550 ARLINGTON BLVD SUITE 325 ROSELLE CENTER FOR HEALING
FAIRFAX VA
22031
US

V. Phone/Fax

Practice location:
  • Phone: 703-698-7117
  • Fax: 703-698-5729
Mailing address:
  • Phone: 703-698-7117
  • Fax: 703-698-5729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0019006433
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: