Healthcare Provider Details

I. General information

NPI: 1063356939
Provider Name (Legal Business Name): ISABEL LUISA TAVAREZ LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 N MAIN ST
CRESTVIEW FL
32536-3544
US

IV. Provider business mailing address

1198 BLACKBERRY CIR
BAKER FL
32531-9366
US

V. Phone/Fax

Practice location:
  • Phone: 850-240-8231
  • Fax:
Mailing address:
  • Phone: 850-240-8231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA100706
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: