Healthcare Provider Details

I. General information

NPI: 1194659631
Provider Name (Legal Business Name): FAIRY THERAPETUIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6884 PIEDMONT CENTER PLZ
GAINESVILLE VA
20155-4035
US

IV. Provider business mailing address

PO BOX 31
BEALETON VA
22712-0031
US

V. Phone/Fax

Practice location:
  • Phone: 571-284-7612
  • Fax:
Mailing address:
  • Phone: 540-571-1880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WM1400X
TaxonomyNurse Massage Therapist (NMT)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name: KASSI MOORE
Title or Position: RELAXATIONAL THERAIPST
Credential:
Phone: 540-571-1880