Provider Demographics
NPI:1184042483
Name:CLISSOLD, LORI JEAN
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:JEAN
Last Name:CLISSOLD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W PLATT ST STE 24
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-2292
Mailing Address - Country:US
Mailing Address - Phone:727-498-8898
Mailing Address - Fax:727-800-6959
Practice Address - Street 1:10033 DR MARTIN LUTHER KING JR ST N STE 300
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-3830
Practice Address - Country:US
Practice Address - Phone:727-498-8898
Practice Address - Fax:727-800-6959
Is Sole Proprietor?:No
Enumeration Date:2014-04-03
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 64886225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist