MEDICARE: BODYLOGIC MASSAGE THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist

General Provider Information

NPI Number	:	1023842309
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BODYLOGIC MASSAGE THERAPY LLC

Provider Business Mailing Address
First Line	:	32780 GRAND RIVER AVE # 212A
Second Line	:
City	:	FARMINGTON
State	:	MI
Zip	:	48336-3138
Country	:	US
Telephone Number	:	947-281-9485
Fax Number	:

Provider Business Practice Location Address
First Line	:	32780 GRAND RIVER AVE # 212A
Second Line	:
City	:	FARMINGTON
State	:	MI
Zip	:	48336-3138
Country	:	US
Telephone Number	:	313-204-8955
Fax Number	:

Authorized Official
Title or Position	:	OWNER/MASSAGE THERAPIST
Name	:	ELIZABETH SHARIS SHAW
Credential	:	LMT
Telephone Number	:	947-281-9485

Provider Enumeration Date	:	08/28/2024
Last Update Date	:	12/24/2025

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