Healthcare Provider Details

I. General information

NPI: 1225368772
Provider Name (Legal Business Name): KELLI EADY M.A., LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2010
Last Update Date: 01/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3541 EDGEWATER DR
ORLANDO FL
32804-2942
US

IV. Provider business mailing address

3541 EDGEWATER DR
ORLANDO FL
32804-2942
US

V. Phone/Fax

Practice location:
  • Phone: 407-423-0038
  • Fax:
Mailing address:
  • Phone: 407-423-0038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA55970
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: