Provider Demographics
NPI:1669212239
Name:MYOFASCIAL RELEASE AND WOMEN'S HEALTH LLC
Entity type:Organization
Organization Name:MYOFASCIAL RELEASE AND WOMEN'S HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:HENNESSY
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:813-482-5765
Mailing Address - Street 1:21514 CORMORANT COVE DR
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34637-7523
Mailing Address - Country:US
Mailing Address - Phone:813-482-5765
Mailing Address - Fax:
Practice Address - Street 1:1527 DALE MABRY HWY STE 105
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-3031
Practice Address - Country:US
Practice Address - Phone:813-482-5765
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1063681526Medicaid