Provider Demographics
NPI:1013121979
Name:GENSON, MAYA (LMT)
Entity Type:Individual
Prefix:MS
First Name:MAYA
Middle Name:
Last Name:GENSON
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 1:805 69TH AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34207-6170
Mailing Address - Country:US
Mailing Address - Phone:941-266-7466
Mailing Address - Fax:
Practice Address - Street 1:8913 US HIGHWAY 301 N
Practice Address - Street 2:
Practice Address - City:PARRISH
Practice Address - State:FL
Practice Address - Zip Code:34219-8701
Practice Address - Country:US
Practice Address - Phone:941-776-3921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA42609171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor