Healthcare Provider Details

I. General information

NPI: 1447461819
Provider Name (Legal Business Name): THERAPEUTIC WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MADRID BLVD SUITE 411
PUNTA GORDA FL
33950-7968
US

IV. Provider business mailing address

100 MADRID BLVD SUITE 411
PUNTA GORDA FL
33950-7968
US

V. Phone/Fax

Practice location:
  • Phone: 941-833-3344
  • Fax: 941-833-0328
Mailing address:
  • Phone: 941-833-3344
  • Fax: 941-833-0328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMM 12309
License Number StateFL

VIII. Authorized Official

Name: KATHLEEN KELLEY
Title or Position: THERAPIST
Credential: L.M.T
Phone: 941-833-3344