Provider Demographics
NPI:1538460282
Name:PEARSON, TIMOTHY G (LMT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:G
Last Name:PEARSON
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 1:217 HUBBELL ST
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32132-1701
Mailing Address - Country:US
Mailing Address - Phone:386-402-1538
Mailing Address - Fax:
Practice Address - Street 1:3404 S ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32169-3626
Practice Address - Country:US
Practice Address - Phone:386-402-1538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-11
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA57576225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA57576OtherMA57576