Healthcare Provider Details

I. General information

NPI: 1629909817
Provider Name (Legal Business Name): ALLISON RAE RADER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6059 DIAMANTE DR
CRESTVIEW FL
32539-9518
US

IV. Provider business mailing address

6059 DIAMANTE DR
CRESTVIEW FL
32539-9518
US

V. Phone/Fax

Practice location:
  • Phone: 813-407-9166
  • Fax:
Mailing address:
  • Phone: 813-407-9166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number109408
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: