Provider Demographics
NPI:1780160200
Name:FOSTERING WELLNESS MASSAGE THERAPY
Entity type:Organization
Organization Name:FOSTERING WELLNESS MASSAGE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LICENSED MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:M
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:LMT, MMP
Authorized Official - Phone:757-323-5139
Mailing Address - Street 1:2736 MEADOW DR W
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-4132
Mailing Address - Country:US
Mailing Address - Phone:757-323-5139
Mailing Address - Fax:
Practice Address - Street 1:3108 TYRE NECK RD STE D
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-4532
Practice Address - Country:US
Practice Address - Phone:757-323-5139
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019006819225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty