Provider Demographics
NPI:1699412213
Name:COLLAZOS, STEPHANIE (LMT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:COLLAZOS
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 1:1107 NW 6TH ST STE F
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32601-2201
Mailing Address - Country:US
Mailing Address - Phone:772-828-8989
Mailing Address - Fax:
Practice Address - Street 1:4343 NEWBERRY RD STE 4
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-2822
Practice Address - Country:US
Practice Address - Phone:352-373-6565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA90871225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist