Provider Demographics
NPI:1275027484
Name:BLANK, LEE ANNE (LMT, RYT200)
Entity Type:Individual
Prefix:MS
First Name:LEE
Middle Name:ANNE
Last Name:BLANK
Suffix:
Gender:F
Credentials:LMT, RYT200
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 EDMONSTON DR
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20851-1040
Mailing Address - Country:US
Mailing Address - Phone:301-762-0416
Mailing Address - Fax:
Practice Address - Street 1:966 HUNGERFORD DR STE 21A
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-1741
Practice Address - Country:US
Practice Address - Phone:301-762-0564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM02823225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDM02823OtherMARYLAND MASSAGE LICENSE