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General NPI Number Information
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NPI Number | 1780160200
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Entity Type | Organization
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Legal Business Name | FOSTERING WELLNESS MASSAGE THERAPY
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Dates
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Enumeration Date | 07/17/2018
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Last Update Date | 07/17/2018
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Provider Practice Location Address
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Address Line | 3108 TYRE NECK RD STE D
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City | PORTSMOUTH
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State | VA
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Zip | 23703-4532
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Country | US
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Telephone | 757-323-5139
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Fax |
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Provider Business Mailing Address
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Address Line | 2736 MEADOW DR W
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City | CHESAPEAKE
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State | VA
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Zip | 23321-4132
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Country | US
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Telephone | 757-323-5139
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Fax |
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Authorized Official
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Title or Position | OWNER/LICENSED MASSAGE THERAPIST
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Name | KELLY M FOSTER
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Credential | LMT, MMP
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Telephone | 757-323-5139
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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 | 0019006819
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License Number State | VA
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