Provider Demographics
NPI:1275246001
Name:THOMPSON, TAWANA (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:TAWANA
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 BROADWAY APT 3
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-2436
Mailing Address - Country:US
Mailing Address - Phone:347-977-2776
Mailing Address - Fax:
Practice Address - Street 1:180 BROADWAY APT 3
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-2436
Practice Address - Country:US
Practice Address - Phone:347-977-2776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-26
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026723-01225700000X
NJ18KT01452600225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist