Provider Demographics
NPI:1740870039
Name:WILLMAN, ALISA S (LMT)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:S
Last Name:WILLMAN
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 1:1616 OSPREY AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-2440
Mailing Address - Country:US
Mailing Address - Phone:917-494-0185
Mailing Address - Fax:
Practice Address - Street 1:2600 WESTHALL LN
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7102
Practice Address - Country:US
Practice Address - Phone:917-494-0185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA95448225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA95448OtherMASSAGE THERAPY LICENSE