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General NPI Number Information
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NPI Number | 1346843026
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Entity Type | Individual
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Provider Name | SERITA BOSTICK LMT
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Gender | Female
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Dates
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Enumeration Date | 11/17/2020
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Last Update Date | 01/02/2023
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Provider Practice Location Address
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Address Line | 4605 PEMBROKE LAKE CIR STE 303
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City | VIRGINIA BEACH
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State | VA
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Zip | 23455-6448
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Country | US
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Telephone | 757-449-0178
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Fax |
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Provider Business Mailing Address
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Address Line | 3300 GWIN ST
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City | PORTSMOUTH
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State | VA
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Zip | 23704-6019
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Country | US
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Telephone | 757-449-0178
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 0019010291
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License Number State | VA
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