Provider Demographics
NPI:1487815817
Name:ABBOTT, STEPHANIE EVELYN (LMT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:EVELYN
Last Name:ABBOTT
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 1:931 S RIDGEWOOD AVE
Mailing Address - Street 2:STE B-6
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32132-2301
Mailing Address - Country:US
Mailing Address - Phone:386-409-0065
Mailing Address - Fax:
Practice Address - Street 1:931 S RIDGEWOOD AVE
Practice Address - Street 2:STE B-6
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32132-2301
Practice Address - Country:US
Practice Address - Phone:386-409-0065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 0016377225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist