Provider Demographics
NPI:1013191196
Name:SMITH, LYDIA SHAWN (BA, LMT)
Entity Type:Individual
Prefix:MISS
First Name:LYDIA
Middle Name:SHAWN
Last Name:SMITH
Suffix:
Gender:F
Credentials:BA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 N. DONNELLY STREET SUITE 311
Mailing Address - Street 2:BENEFICIAL MASSAGE
Mailing Address - City:MT. DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757
Mailing Address - Country:US
Mailing Address - Phone:352-383-8007
Mailing Address - Fax:
Practice Address - Street 1:411 N. DONNELLY STREET SUITE 311
Practice Address - Street 2:BENEFICIAL MASSAGE
Practice Address - City:MT. DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-5596
Practice Address - Country:US
Practice Address - Phone:352-383-8007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA0008807225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist