=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174074009
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NYC BODYWORKS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2016
-----------------------------------------------------
Last Update Date | 10/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1123 BROADWAY STE 1009
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10010-2007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-463-9461
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1123 BROADWAY STE 1009
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10010-2007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-463-9461
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | SUSAN SHOCKETT
-----------------------------------------------------
Credential | LMT, BCSI
-----------------------------------------------------
Telephone | 212-463-9461
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 20723
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------