Provider Demographics
NPI:1720611189
Name:DAVIS, MARIE THERESA (LMT)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:THERESA
Last Name:DAVIS
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 1:1000 NE 191ST ST APT F26
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33179-4054
Mailing Address - Country:US
Mailing Address - Phone:786-274-3346
Mailing Address - Fax:
Practice Address - Street 1:1000 NE 191ST ST APT F26
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33179-4054
Practice Address - Country:US
Practice Address - Phone:786-274-3346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA60907225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist