Provider Demographics
NPI:1629695804
Name:RAYBURN, THOMAS SCOTT (LMT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:SCOTT
Last Name:RAYBURN
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 1:648 E HILLCREST ST
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-2636
Mailing Address - Country:US
Mailing Address - Phone:407-919-9119
Mailing Address - Fax:
Practice Address - Street 1:2111 E MICHIGAN ST STE 202
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-4973
Practice Address - Country:US
Practice Address - Phone:407-919-9119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-03
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA85452225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist