Provider Demographics
NPI:1922255660
Name:COULLIETTE, JAMES RUFUS JR (LMT)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:RUFUS
Last Name:COULLIETTE
Suffix:JR
Gender:M
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:PO BOX 895321
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34789-5321
Mailing Address - Country:US
Mailing Address - Phone:352-455-7828
Mailing Address - Fax:
Practice Address - Street 1:33306 PORTAL DR
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34788-3171
Practice Address - Country:US
Practice Address - Phone:352-253-2353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-25
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA-45688225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA-45688OtherLICENSED MASSAGE THERAPIST