Provider Demographics
NPI:1902025711
Name:THERAPEUTIC BODYWORK & MASSAGE, INC
Entity Type:Organization
Organization Name:THERAPEUTIC BODYWORK & MASSAGE, INC
Other - Org Name:7TH STREET RETREAT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:FUSILIER
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:850-747-1277
Mailing Address - Street 1:303 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-3032
Mailing Address - Country:US
Mailing Address - Phone:850-747-1277
Mailing Address - Fax:850-784-4441
Practice Address - Street 1:303 E 7TH ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-3032
Practice Address - Country:US
Practice Address - Phone:850-747-1277
Practice Address - Fax:850-784-4441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 41685225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC3868OtherBLUE CROSS BLUE SHIELD