Provider Demographics
NPI:1821708389
Name:ELLERBE, LAURA (LMT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:ELLERBE
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 1:400 SYBELIA PKWY UNIT 533
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4635
Mailing Address - Country:US
Mailing Address - Phone:321-439-3830
Mailing Address - Fax:
Practice Address - Street 1:400 SYBELIA PKWY UNIT 533
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4635
Practice Address - Country:US
Practice Address - Phone:321-439-3830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-24
Last Update Date:2022-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA68679225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist