Provider Demographics
NPI:1821371667
Name:MORA, GRAZIELLA G (BS, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:GRAZIELLA
Middle Name:G
Last Name:MORA
Suffix:
Gender:F
Credentials:BS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2721 MINT DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-9512
Mailing Address - Country:US
Mailing Address - Phone:407-489-5614
Mailing Address - Fax:407-992-8663
Practice Address - Street 1:2721 MINT DR.
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837
Practice Address - Country:US
Practice Address - Phone:407-489-5614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-27
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 31862255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer