Provider Demographics
NPI:1689318065
Name:HARRIS, GERRODDICKA L (LMT)
Entity Type:Individual
Prefix:
First Name:GERRODDICKA
Middle Name:L
Last Name:HARRIS
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 1:8923 AVENUE CLUB DR UNIT 202
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-5840
Mailing Address - Country:US
Mailing Address - Phone:813-965-5276
Mailing Address - Fax:
Practice Address - Street 1:8923 AVENUE CLUB DR UNIT 202
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33637-5840
Practice Address - Country:US
Practice Address - Phone:813-965-5276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-22
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA69393225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH620292867250OtherLICENSE