Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | MA0008807 | FL |
NPI | 1013191196 |
---|---|
Provider Name | Miss Lydia Shawn Smith |
First Address | Mt. Dora, FL 32757 |
Second Address | Mt. Dora, FL 32757-5596 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/12/2007 |
Last Update Date | 24/12/2007 |