Provider Demographics
NPI:1326307455
Name:CHURCHILL, KRISTIN LEAH (LMT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:LEAH
Last Name:CHURCHILL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 EXETER AVE
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-3546
Mailing Address - Country:US
Mailing Address - Phone:352-396-4877
Mailing Address - Fax:
Practice Address - Street 1:1450 E NORTH BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5393
Practice Address - Country:US
Practice Address - Phone:352-396-4877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-09
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 63999225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist