=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609261593
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FUNCTIONAL MASSAGE THERAPY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2015
-----------------------------------------------------
Last Update Date | 03/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 755 WAVERLY AVE SUITE #206
-----------------------------------------------------
City | HOLTSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11742-1190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-730-8300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 755 WAVERLY AVE SUITE #206
-----------------------------------------------------
City | HOLTSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11742-1190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-730-8300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/LICENSED MASSAGE THERAPIST
-----------------------------------------------------
Name | SHERRY COLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 631-730-8300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 018019
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------