Healthcare Provider Details

I. General information

NPI: 1164657656
Provider Name (Legal Business Name): ROBIN J WURTH LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2009
Last Update Date: 01/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 ROLLING ACRES RD SUITE 1
LADY LAKE FL
32159-5028
US

IV. Provider business mailing address

10548 SE HIGHWAY 42 SUITE 1
SUMMERFIELD FL
34491-6633
US

V. Phone/Fax

Practice location:
  • Phone: 352-804-7138
  • Fax:
Mailing address:
  • Phone: 352-804-7138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 53963
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: