Provider Demographics
NPI:1891222303
Name:FOSFOROVA, OLENA (LMBT)
Entity Type:Individual
Prefix:
First Name:OLENA
Middle Name:
Last Name:FOSFOROVA
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 S MINT ST STE 109
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-4058
Mailing Address - Country:US
Mailing Address - Phone:704-763-9044
Mailing Address - Fax:
Practice Address - Street 1:1100 S MINT ST STE 109
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-4058
Practice Address - Country:US
Practice Address - Phone:704-763-9044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12549225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty