Provider Demographics
NPI:1386829455
Name:BLACK, PAULA (LMT)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:
Last Name:BLACK
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 1:37110 SHALIMAR DR
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:34731-5693
Mailing Address - Country:US
Mailing Address - Phone:352-217-5913
Mailing Address - Fax:800-878-6689
Practice Address - Street 1:2430 S BAY ST
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-6363
Practice Address - Country:US
Practice Address - Phone:352-217-5913
Practice Address - Fax:800-878-6689
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-08
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA41889225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC2910OtherBCBS