=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205321106
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUSTAINABILITY WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2018
-----------------------------------------------------
Last Update Date | 06/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8415 BELLONA LN STE 202
-----------------------------------------------------
City | TOWSON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21204-2066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-846-6009
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8415 BELLONA LN STE 202
-----------------------------------------------------
City | TOWSON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21204-2066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-846-6009
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MASSAGE THERAPIST/INSTRUCTOR
-----------------------------------------------------
Name | ERIC SCOTT JONES WILLIAMS
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 443-846-6009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | M05929
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | U02157
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------