Provider Demographics
NPI:1669923058
Name:BRANDYWINE BODYWORK
Entity type:Organization
Organization Name:BRANDYWINE BODYWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SHAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:302-798-0801
Mailing Address - Street 1:1400 PHILADELPHIA PIKE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19809-1856
Mailing Address - Country:US
Mailing Address - Phone:302-798-0801
Mailing Address - Fax:302-798-3127
Practice Address - Street 1:1400 PHILADELPHIA PIKE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19809-1856
Practice Address - Country:US
Practice Address - Phone:302-798-0801
Practice Address - Fax:302-798-3127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEMT0004411225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty