Provider Demographics
NPI:1841314747
Name:HERODEK, ROSITA (LMT)
Entity type:Individual
Prefix:MS
First Name:ROSITA
Middle Name:
Last Name:HERODEK
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 1:5845 CAPE ISLAND DR
Mailing Address - Street 2:# A
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-4429
Mailing Address - Country:US
Mailing Address - Phone:239-357-8442
Mailing Address - Fax:
Practice Address - Street 1:823 LAKE MCGREGOR DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-6209
Practice Address - Country:US
Practice Address - Phone:239-357-8442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0028882225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist