Provider Demographics
NPI:1639681133
Name:DUDLEY-GREGORY, PATRICIA LOUISE (LMT)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:LOUISE
Last Name:DUDLEY-GREGORY
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 1:110 E 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:HAVANA
Mailing Address - State:FL
Mailing Address - Zip Code:32333-1620
Mailing Address - Country:US
Mailing Address - Phone:850-616-1305
Mailing Address - Fax:
Practice Address - Street 1:110 E 7TH AVE
Practice Address - Street 2:
Practice Address - City:HAVANA
Practice Address - State:FL
Practice Address - Zip Code:32333-1620
Practice Address - Country:US
Practice Address - Phone:850-616-1305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA82215225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty