Provider Demographics
NPI:1922491125
Name:BODY BALANCE MASSAGE THERAPY
Entity Type:Organization
Organization Name:BODY BALANCE MASSAGE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KENNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:718-683-1905
Mailing Address - Street 1:1822 ASTORIA PARK S
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-3444
Mailing Address - Country:US
Mailing Address - Phone:718-683-1905
Mailing Address - Fax:
Practice Address - Street 1:850 7TH AVE
Practice Address - Street 2:SUITE 606
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-5230
Practice Address - Country:US
Practice Address - Phone:718-683-1905
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-11
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY27018013225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty