Provider Demographics
NPI:1619241825
Name:PHYSICAL & MASSAGE THERAPY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:PHYSICAL & MASSAGE THERAPY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LMT
Authorized Official - Prefix:MS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MASSAGE THERAPIST
Authorized Official - Phone:304-431-3535
Mailing Address - Street 1:463D OLD BLUEFIELD RD
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24739-8927
Mailing Address - Country:US
Mailing Address - Phone:304-431-3535
Mailing Address - Fax:
Practice Address - Street 1:463D OLD BLUEFIELD RD
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24739-8927
Practice Address - Country:US
Practice Address - Phone:304-431-3535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002466225100000X
WV20102705225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV002466OtherPHYSICAL THERAPIST STATE LICENSE
WV20102705OtherSTATE LICENSE NUMBER