Provider Demographics
NPI:1861685273
Name:DE LA GARZA, DANIEL EDWARD (LMT)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:EDWARD
Last Name:DE LA GARZA
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:MR
Other - First Name:DANNY
Other - Middle Name:EDWARD
Other - Last Name:DE LA GARZA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:4872 OUTLOOK DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-2334
Mailing Address - Country:US
Mailing Address - Phone:321-536-2173
Mailing Address - Fax:
Practice Address - Street 1:6300 N WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-2028
Practice Address - Country:US
Practice Address - Phone:321-536-2173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 47051225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist