Provider Demographics
NPI:1790112795
Name:MAYNE-OWEN, PHYLEISCHA MATESE (HHP,LMT, CPT)
Entity Type:Individual
Prefix:MRS
First Name:PHYLEISCHA
Middle Name:MATESE
Last Name:MAYNE-OWEN
Suffix:
Gender:F
Credentials:HHP,LMT, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6128 GOLDEN DEWDROP TRAIL
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786
Mailing Address - Country:US
Mailing Address - Phone:407-312-4613
Mailing Address - Fax:407-614-4149
Practice Address - Street 1:2658 MAGUIRE RD
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761
Practice Address - Country:US
Practice Address - Phone:407-312-4613
Practice Address - Fax:407-614-4122
Is Sole Proprietor?:No
Enumeration Date:2013-10-04
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
FLMA55794225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist