Healthcare Provider Details

I. General information

NPI: 1912110362
Provider Name (Legal Business Name): CLEAR PASSAGE THERAPIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 05/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4421 NW 39TH AVENUE STE 2-2
GAINESVILLE FL
32606
US

IV. Provider business mailing address

4421 NW 39TH AVENUE STE 2-2
GAINESVILLE FL
32606
US

V. Phone/Fax

Practice location:
  • Phone: 352-336-1433
  • Fax: 352-336-9980
Mailing address:
  • Phone: 352-336-1433
  • Fax: 352-336-9980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: TRACY WAGNER
Title or Position: ADMINISTRATOR
Credential:
Phone: 352-336-1433