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General NPI Number Information
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NPI Number | 1881337400
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Entity Type | Organization
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Legal Business Name | THETA MASSAGE AND BODYWORK LLC.
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Dates
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Enumeration Date | 04/20/2022
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Last Update Date | 04/20/2022
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Provider Practice Location Address
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Address Line | 255 FLYNN AVE
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City | BURLINGTON
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State | VT
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Zip | 05401-5303
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Country | US
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Telephone | 336-575-6124
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Fax |
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Provider Business Mailing Address
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Address Line | 255 FLYNN AVE
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City | BURLINGTON
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State | VT
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Zip | 05401-5303
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Country | US
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Telephone | 336-575-6124
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Fax |
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Authorized Official
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Title or Position | CO-OWNER
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Name | EMILY DAYLE JORDAN
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Credential | LMBT
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Telephone | 336-575-6124
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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 |
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License Number State |
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