Provider Demographics
NPI:1558073049
Name:BOISSELLE, ROBERTA JEAN (LMT)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:JEAN
Last Name:BOISSELLE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:ROBERTA
Other - Middle Name:JEAN
Other - Last Name:SALANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:PO BOX 951
Mailing Address - Street 2:
Mailing Address - City:WEST END
Mailing Address - State:NC
Mailing Address - Zip Code:27376-0951
Mailing Address - Country:US
Mailing Address - Phone:910-673-2000
Mailing Address - Fax:
Practice Address - Street 1:980 SEVEN LAKES DRIVE
Practice Address - Street 2:SUITE 3
Practice Address - City:SEVEN LAKES
Practice Address - State:NC
Practice Address - Zip Code:27376
Practice Address - Country:US
Practice Address - Phone:910-673-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-16
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC01573225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC01573OtherNORTH CAROLINA BOARD OF MASSAGE THERAPY AND BODYWORK LICENSE