Provider Demographics
NPI:1417350513
Name:GRUENEWALD, DIANE (LMT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:GRUENEWALD
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 1:1487 2ND ST
Mailing Address - Street 2:C
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34236-4911
Mailing Address - Country:US
Mailing Address - Phone:941-374-1281
Mailing Address - Fax:
Practice Address - Street 1:1487 2ND ST
Practice Address - Street 2:C
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236-4911
Practice Address - Country:US
Practice Address - Phone:941-374-1281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-02
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA40011173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA40011OtherMASSAGE THERAPY
MM26912OtherMASSAGE THERAPY BUSINESS