Provider Demographics
NPI:1700198306
Name:360 NEUROMUSCULAR THERAPY, LLC
Entity Type:Organization
Organization Name:360 NEUROMUSCULAR THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ERICKSON GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CNMT, CMTPT
Authorized Official - Phone:781-444-3609
Mailing Address - Street 1:1077 LEXINGTON ST STE 202
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02452-7233
Mailing Address - Country:US
Mailing Address - Phone:781-444-3609
Mailing Address - Fax:781-209-7301
Practice Address - Street 1:1077 LEXINGTON ST STE 202
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02452-7233
Practice Address - Country:US
Practice Address - Phone:781-444-3609
Practice Address - Fax:781-209-7301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-12
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA167225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty