Provider Demographics
NPI:1083041065
Name:GAVIDIA, DESIRAE MADISON (LMT, MMP)
Entity Type:Individual
Prefix:MISS
First Name:DESIRAE
Middle Name:MADISON
Last Name:GAVIDIA
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 SW TIMBER TRL
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-6266
Mailing Address - Country:US
Mailing Address - Phone:772-497-6126
Mailing Address - Fax:
Practice Address - Street 1:555 COLORADO AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-3025
Practice Address - Country:US
Practice Address - Phone:772-497-6126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-04
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA65422225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist