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General NPI Number Information
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NPI Number | 1750620167
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Entity Type | Organization
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Legal Business Name | DEDICATED MASSAGE THERAPY P.C
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Dates
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Enumeration Date | 02/05/2013
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Last Update Date | 02/05/2013
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Provider Practice Location Address
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Address Line | 392 15TH ST
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City | WEST BABYLON
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State | NY
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Zip | 11704-2615
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Country | US
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Telephone | 631-983-7799
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Fax | 631-957-9022
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Provider Business Mailing Address
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Address Line | 392 15TH ST
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City | WEST BABYLON
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State | NY
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Zip | 11704-2615
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Country | US
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Telephone | 631-983-7799
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Fax | 631-957-9022
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Authorized Official
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Title or Position | PRESIDENT / MASSAGE THERAPIST
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Name | MISS STACY M THORNELL
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Credential |
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Telephone | 631-983-7799
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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 | 020790-1
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License Number State | NY
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