Healthcare Provider Details

I. General information

NPI: 1730630005
Provider Name (Legal Business Name): KRISTINE LEUVELINK GODDARD MASSAGE THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 10/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6829 ELM ST STE 300
MC LEAN VA
22101-3845
US

IV. Provider business mailing address

6829 ELM ST STE 300
MC LEAN VA
22101-3845
US

V. Phone/Fax

Practice location:
  • Phone: 703-532-4892
  • Fax:
Mailing address:
  • Phone: 703-532-4892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0019002714
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: