Provider Demographics
NPI:1235341439
Name:DOUGLAS, SYLVIA WILLIS (LMT)
Entity Type:Individual
Prefix:MS
First Name:SYLVIA
Middle Name:WILLIS
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:9764 SW TUSTENUGGEE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32024-1439
Mailing Address - Country:US
Mailing Address - Phone:386-754-2821
Mailing Address - Fax:386-754-2822
Practice Address - Street 1:2086 SW MAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-0005
Practice Address - Country:US
Practice Address - Phone:386-754-2821
Practice Address - Fax:386-754-2822
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA31731225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist