MEDICARE: MAHOGANY DESIREE WOOLFOLK AAS, LMT

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	0019011549	VA

General Provider Information

NPI Number	:	1447747712
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAHOGANY DESIREE WOOLFOLK AAS, LMT

Provider Business Mailing Address
First Line	:	2920 W STONY HILL CT APT 2B
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23235-6851
Country	:	US
Telephone Number	:	804-569-5184
Fax Number	:

Provider Business Practice Location Address
First Line	:	1221 MALL DR STE 202
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23235-4737
Country	:	US
Telephone Number	:	804-569-5184
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/22/2018
Last Update Date	:	04/22/2018

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