Provider Demographics
NPI:1194433391
Name:GIRVIN, LANDON ELIZABETH
Entity type:Individual
Prefix:
First Name:LANDON
Middle Name:ELIZABETH
Last Name:GIRVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LANDON
Other - Middle Name:ELIZABETH
Other - Last Name:LUSH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMBT
Mailing Address - Street 1:504 KEYS LN
Mailing Address - Street 2:
Mailing Address - City:CAROLINA BCH
Mailing Address - State:NC
Mailing Address - Zip Code:28428-4730
Mailing Address - Country:US
Mailing Address - Phone:808-633-3943
Mailing Address - Fax:
Practice Address - Street 1:915 LAKE PARK BLVD N
Practice Address - Street 2:
Practice Address - City:CAROLINA BCH
Practice Address - State:NC
Practice Address - Zip Code:28428-4851
Practice Address - Country:US
Practice Address - Phone:910-448-4965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19361225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC19361OtherMASSAGE THERAPIST LICENSE