=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922978840
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREEN OWL BODY THERAPIES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2025
-----------------------------------------------------
Last Update Date | 11/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5910 WAXHAW HWY SUITE B
-----------------------------------------------------
City | MINERAL SPRINGS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-771-2774
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6907 BIRDSONG LN
-----------------------------------------------------
City | WAXHAW
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28173-7407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-771-2774
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | MR. WILLIAM GRAY LEHAN JR.
-----------------------------------------------------
Credential | LBMT
-----------------------------------------------------
Telephone | 704-771-2774
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------