Provider Demographics
NPI:1922367655
Name:PHILLIPS, JODY A (LMT, CNA)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:A
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LMT, CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 TAMIAMI TRL S STE B
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-5002
Mailing Address - Country:US
Mailing Address - Phone:941-525-4878
Mailing Address - Fax:
Practice Address - Street 1:1901 TAMIAMI TRL S STE B
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-5002
Practice Address - Country:US
Practice Address - Phone:941-525-4878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA56081225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist