Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | MA28686 | FL |
NPI | 1013416783 |
---|---|
Provider Name | Theresa Marie Revell |
First Address | Tallahassee, FL 32309-1615 |
Second Address | Tallahassee, FL 32309-1615 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/02/2018 |
Last Update Date | 07/02/2018 |