Provider Demographics
NPI:1356164941
Name:SILLS, CAROLYN (MA , LMT)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:SILLS
Suffix:
Gender:F
Credentials:MA , LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 BANANA BLVD
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-5142
Mailing Address - Country:US
Mailing Address - Phone:321-514-7057
Mailing Address - Fax:
Practice Address - Street 1:264 N GROVE ST
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-3444
Practice Address - Country:US
Practice Address - Phone:321-375-4397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA105945225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist