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General NPI Number Information
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NPI Number | 1689084436
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Entity Type | Organization
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Legal Business Name | BALANCED BODY MASSAGE GROUP
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Dates
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Enumeration Date | 05/02/2014
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Last Update Date | 05/02/2014
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Provider Practice Location Address
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Address Line | 9500 MARLBORO PIKE SUITE 12
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City | UPPER MARLBORO
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State | MD
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Zip | 20772
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Country | US
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Telephone | 301-702-8555
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Fax | 301-702-8005
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Provider Business Mailing Address
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Address Line | 9500 MARLBORO PIKE SUITE 12
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City | UPPER MARLBORO
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State | MD
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Zip | 20772
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Country | US
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Telephone | 301-702-8555
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Fax | 301-702-8005
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Authorized Official
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Title or Position | LICENSED MASSAGE THERAPIST
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Name | SHADONNE HARRIS
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Credential | LMT
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Telephone | 301-702-8555
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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 | 3409
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License Number State | MD
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