Healthcare Provider Details

I. General information

NPI: 1669212239
Provider Name (Legal Business Name): MYOFASCIAL RELEASE AND WOMEN'S HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2024
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1527 DALE MABRY HWY STE 105
LUTZ FL
33548-3031
US

IV. Provider business mailing address

21514 CORMORANT COVE DR
LAND O LAKES FL
34637-7523
US

V. Phone/Fax

Practice location:
  • Phone: 813-482-5765
  • Fax:
Mailing address:
  • Phone: 813-482-5765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN J HENNESSY
Title or Position: MGR
Credential: DPT
Phone: 813-482-5765