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General NPI Number Information
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NPI Number | 1700198306
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Entity Type | Organization
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Legal Business Name | 360 NEUROMUSCULAR THERAPY, LLC
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Dates
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Enumeration Date | 07/12/2010
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Last Update Date | 02/22/2019
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Provider Practice Location Address
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Address Line | 1077 LEXINGTON ST STE 202
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City | WALTHAM
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State | MA
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Zip | 02452-7233
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Country | US
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Telephone | 781-444-3609
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Fax | 781-209-7301
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Provider Business Mailing Address
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Address Line | 1077 LEXINGTON ST STE 202
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City | WALTHAM
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State | MA
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Zip | 02452-7233
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Country | US
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Telephone | 781-444-3609
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Fax | 781-209-7301
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Authorized Official
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Title or Position | CO-OWNER
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Name | MS. LISA MARIE ERICKSON GORMAN
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Credential | CNMT, CMTPT
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Telephone | 781-444-3609
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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 | 167
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License Number State | MA
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