Provider Demographics
NPI:1376810762
Name:GUILDERSON, MARITA (LMT)
Entity Type:Individual
Prefix:
First Name:MARITA
Middle Name:
Last Name:GUILDERSON
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 1:14253 NW 232ND ST
Mailing Address - Street 2:
Mailing Address - City:HIGH SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32643-6855
Mailing Address - Country:US
Mailing Address - Phone:386-454-3761
Mailing Address - Fax:
Practice Address - Street 1:14253 NW 232ND ST
Practice Address - Street 2:
Practice Address - City:HIGH SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32643-6855
Practice Address - Country:US
Practice Address - Phone:386-454-3761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA11218171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor