MEDICARE: WANDA LARRIE NAYEEMA ARCHIE-RAHEEM CMT

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	17329	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	17329	OTHER	NC	NCBTMB

General Provider Information

NPI Number	:	1790167690
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WANDA LARRIE NAYEEMA ARCHIE-RAHEEM CMT

Provider Business Mailing Address
First Line	:	115 S COOL SPRING ST
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28301-5723
Country	:	US
Telephone Number	:	803-873-7388
Fax Number	:	888-965-9470

Provider Business Practice Location Address
First Line	:	115 S COOL SPRING ST STE 1-A
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28301-5723
Country	:	US
Telephone Number	:	803-873-7388
Fax Number	:	888-965-9470

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

Provider Enumeration Date	:	06/26/2015
Last Update Date	:	06/15/2026

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