Provider Demographics
NPI:1104532472
Name:BAILEY, JODIE (LMBT, MLD-C, CST)
Entity type:Individual
Prefix:
First Name:JODIE
Middle Name:
Last Name:BAILEY
Suffix:
Gender:F
Credentials:LMBT, MLD-C, CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10726 WAYCROSS DR
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-2641
Mailing Address - Country:US
Mailing Address - Phone:704-359-7100
Mailing Address - Fax:
Practice Address - Street 1:20830 TORRENCE CHAPEL RD UNIT 101
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-0300
Practice Address - Country:US
Practice Address - Phone:704-359-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20599225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist