Provider Demographics
NPI:1376742791
Name:TODISCO, CAROL BERRY (LMT)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:BERRY
Last Name:TODISCO
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 1:3084 LAKE WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-7613
Mailing Address - Country:US
Mailing Address - Phone:321-259-5056
Mailing Address - Fax:
Practice Address - Street 1:3084 LAKE WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7613
Practice Address - Country:US
Practice Address - Phone:321-259-5056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL42074225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL42074OtherSTATE OF FLORIDA DEPT OF