Provider Demographics
NPI:1689180663
Name:LIBONATI, JAMES (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:LIBONATI
Suffix:
Gender:M
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 W OAKLAND PARK BLVD APT C5
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33311-1744
Mailing Address - Country:US
Mailing Address - Phone:954-600-5843
Mailing Address - Fax:954-653-2955
Practice Address - Street 1:1881 NE 26TH ST STE 200A
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33305-1427
Practice Address - Country:US
Practice Address - Phone:954-600-5843
Practice Address - Fax:954-653-2955
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-28
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA50898225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL693030100Medicaid