Provider Demographics
NPI:1770753220
Name:FLETCHER (MCCRAE), DIANE ELIZABETH (LMT)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:ELIZABETH
Last Name:FLETCHER (MCCRAE)
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 1:235 CARDINAL DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32951-3734
Mailing Address - Country:US
Mailing Address - Phone:321-676-6191
Mailing Address - Fax:
Practice Address - Street 1:2200 FRONT ST STE 200
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-7500
Practice Address - Country:US
Practice Address - Phone:321-723-7716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 47938225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist