Provider Demographics
NPI:1518117225
Name:BLAISE, JOHNSON (LMT)
Entity Type:Individual
Prefix:
First Name:JOHNSON
Middle Name:
Last Name:BLAISE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2648 W SR 434
Mailing Address - Street 2:SUITE C
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-4440
Mailing Address - Country:US
Mailing Address - Phone:407-788-7778
Mailing Address - Fax:407-788-7770
Practice Address - Street 1:2648 W SR 434
Practice Address - Street 2:SUITE C
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-4440
Practice Address - Country:US
Practice Address - Phone:407-788-7778
Practice Address - Fax:407-788-7770
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA52522225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist