Healthcare Provider Details

I. General information

NPI: 1003974312
Provider Name (Legal Business Name): AMY ELIZABETH MCKAY CMT, NCMMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12030 N SHORE DR
RESTON VA
20190-4987
US

IV. Provider business mailing address

PO BOX 8384
RESTON VA
20195-2284
US

V. Phone/Fax

Practice location:
  • Phone: 703-850-3746
  • Fax:
Mailing address:
  • Phone: 703-850-3746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0019001948
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: