Provider Demographics
NPI:1376872226
Name:ESCALONA, MYDOLLY (LMT)
Entity Type:Individual
Prefix:MS
First Name:MYDOLLY
Middle Name:
Last Name:ESCALONA
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 1:2901 W BUSCH BLVD
Mailing Address - Street 2:SUITE 1018
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-4523
Mailing Address - Country:US
Mailing Address - Phone:813-374-0128
Mailing Address - Fax:813-374-0181
Practice Address - Street 1:2901 W BUSCH BLVD
Practice Address - Street 2:SUITE 1018
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-4523
Practice Address - Country:US
Practice Address - Phone:813-374-0128
Practice Address - Fax:813-374-0181
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-23
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA57689225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist