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General NPI Number Information
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NPI Number | 1679302897
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Entity Type | Individual
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Provider Name | MALETA ANDREA BRUCE LMBT
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Gender | Female
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Dates
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Enumeration Date | 07/27/2024
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Last Update Date | 07/27/2024
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Provider Practice Location Address
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Address Line | 1200 E MOREHEAD ST STE 20Q
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City | CHARLOTTE
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State | NC
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Zip | 28204-2872
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Country | US
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Telephone | 704-712-0413
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Fax |
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Provider Business Mailing Address
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Address Line | 8807 KIRCHENBAUM DR
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City | CHARLOTTE
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State | NC
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Zip | 28210-7657
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Country | US
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Telephone | 704-712-0413
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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 | 13583
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 21419
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License Number State | NC
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