Provider Demographics
NPI:1144760273
Name:OUTERBANKS MASSAGE WITH GOULET (OMG)
Entity Type:Organization
Organization Name:OUTERBANKS MASSAGE WITH GOULET (OMG)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL MASSAGE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GOULET
Authorized Official - Suffix:
Authorized Official - Credentials:BMBT, MMP
Authorized Official - Phone:252-305-0285
Mailing Address - Street 1:12 JUNIPER TRL STE 203
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN SHORES
Mailing Address - State:NC
Mailing Address - Zip Code:27949-3745
Mailing Address - Country:US
Mailing Address - Phone:252-305-0285
Mailing Address - Fax:
Practice Address - Street 1:12 JUNIPER TRL STE 203
Practice Address - Street 2:
Practice Address - City:SOUTHERN SHORES
Practice Address - State:NC
Practice Address - Zip Code:27949-3745
Practice Address - Country:US
Practice Address - Phone:252-305-0285
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14500253Z00000X, 261QP2000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
No253Z00000XAgenciesIn Home Supportive Care
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy