Provider Demographics
NPI:1760760680
Name:BODY BALANCE THERAPEUTIC MASSAGE
Entity Type:Organization
Organization Name:BODY BALANCE THERAPEUTIC MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, LICENSE MASSAGED THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:LAONE
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:860-621-0061
Mailing Address - Street 1:17 MERIDEN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-3227
Mailing Address - Country:US
Mailing Address - Phone:860-621-0061
Mailing Address - Fax:860-621-0061
Practice Address - Street 1:17 MERIDEN AVE
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-3227
Practice Address - Country:US
Practice Address - Phone:860-621-0061
Practice Address - Fax:860-621-0061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002078225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty