Provider Demographics
NPI:1922629708
Name:GALLENTINE, JOANN JODY (PHD LMT)
Entity Type:Individual
Prefix:
First Name:JOANN
Middle Name:JODY
Last Name:GALLENTINE
Suffix:
Gender:F
Credentials:PHD LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16215 ENCLAVE VILLAGE DR # 108
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-5102
Mailing Address - Country:US
Mailing Address - Phone:813-510-9904
Mailing Address - Fax:
Practice Address - Street 1:16215 ENCLAVE VILLAGE DR # 108
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-5102
Practice Address - Country:US
Practice Address - Phone:813-510-9904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-02
Last Update Date:2020-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA74868225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist