Provider Demographics
NPI:1154060424
Name:PRESCOD, SEAN (MA)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:PRESCOD
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10720 CLEAR LAKE LOOP APT 289
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-5479
Mailing Address - Country:US
Mailing Address - Phone:239-672-9452
Mailing Address - Fax:
Practice Address - Street 1:10720 CLEAR LAKE LOOP APT 289
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-5479
Practice Address - Country:US
Practice Address - Phone:239-672-9452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA89320225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist