Healthcare Provider Details

I. General information

NPI: 1649495540
Provider Name (Legal Business Name): FORREST OLIVIA MARSTON L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 FLORIDA AVE SUITE C
PALM HARBOR FL
34683-4331
US

IV. Provider business mailing address

2713 FOX FIRE CT
CLEARWATER FL
33761-3722
US

V. Phone/Fax

Practice location:
  • Phone: 727-772-1966
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License NumberMA43667
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: