Provider Demographics
NPI:1417406653
Name:NEW MOON BODYWORK AND WELLNESS
Entity Type:Organization
Organization Name:NEW MOON BODYWORK AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR/MASSAGE THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:207-602-8583
Mailing Address - Street 1:55 LAMBERT ST
Mailing Address - Street 2:APT 13
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2130
Mailing Address - Country:US
Mailing Address - Phone:207-602-8583
Mailing Address - Fax:
Practice Address - Street 1:16 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-3717
Practice Address - Country:US
Practice Address - Phone:207-602-8583
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT4268225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty