Provider Demographics
NPI:1689725186
Name:SERVILLAS, LADY MICHELLE (PT)
Entity Type:Individual
Prefix:
First Name:LADY
Middle Name:MICHELLE
Last Name:SERVILLAS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LADY
Other - Middle Name:MICHELLE
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4050 NE 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:LIGHTHOUSE POINT
Mailing Address - State:FL
Mailing Address - Zip Code:33064-8424
Mailing Address - Country:US
Mailing Address - Phone:305-318-5115
Mailing Address - Fax:561-431-2691
Practice Address - Street 1:4050 NE 30TH AVE
Practice Address - Street 2:
Practice Address - City:LIGHTHOUSE POINT
Practice Address - State:FL
Practice Address - Zip Code:33064-8424
Practice Address - Country:US
Practice Address - Phone:305-318-5115
Practice Address - Fax:888-506-5776
Is Sole Proprietor?:No
Enumeration Date:2007-01-13
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21805225100000X
FL21805225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist