Provider Demographics
NPI:1508084393
Name:STREET, CAROLYN K (LMT)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:K
Last Name:STREET
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12257 PEACEFUL AVE
Mailing Address - Street 2:
Mailing Address - City:WEEKI WACHEE
Mailing Address - State:FL
Mailing Address - Zip Code:34614-1906
Mailing Address - Country:US
Mailing Address - Phone:352-597-8996
Mailing Address - Fax:352-597-2809
Practice Address - Street 1:6226 COMMERCIAL WAY
Practice Address - Street 2:
Practice Address - City:WEEKI WACHEE
Practice Address - State:FL
Practice Address - Zip Code:34613-6325
Practice Address - Country:US
Practice Address - Phone:352-597-8996
Practice Address - Fax:352-597-2809
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA17146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist