Provider Demographics
NPI:1003060625
Name:RAYBURN, JOEL (LMT)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:RAYBURN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 E CRYSTAL LAKE ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-4515
Mailing Address - Country:US
Mailing Address - Phone:407-897-5377
Mailing Address - Fax:
Practice Address - Street 1:2111 E MICHIGAN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-4983
Practice Address - Country:US
Practice Address - Phone:407-897-5377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-10
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 0017506225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist