Provider Demographics
NPI:1083949598
Name:TERRY, IAN LW (LMT)
Entity Type:Individual
Prefix:MR
First Name:IAN
Middle Name:LW
Last Name:TERRY
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 1:1161 ISLAND SHORE LN
Mailing Address - Street 2:APT #231
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5396
Mailing Address - Country:US
Mailing Address - Phone:321-262-3905
Mailing Address - Fax:
Practice Address - Street 1:1161 ISLAND SHORE LN
Practice Address - Street 2:APT #231
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-5396
Practice Address - Country:US
Practice Address - Phone:321-262-3905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-16
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA56779225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist