Provider Demographics
NPI:1376720300
Name:BELLOW, JOANNE RUTH (LMBT)
Entity Type:Individual
Prefix:MS
First Name:JOANNE
Middle Name:RUTH
Last Name:BELLOW
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13024 YALE BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32735-8956
Mailing Address - Country:US
Mailing Address - Phone:352-638-0391
Mailing Address - Fax:
Practice Address - Street 1:17521 US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6737
Practice Address - Country:US
Practice Address - Phone:352-638-0391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-22
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA47425174400000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL300608921Medicaid
FL692420496Medicaid
FL30030608921Medicaid