=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033222526
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GINA MARIE STAVREDES L.M.T.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2006
-----------------------------------------------------
Last Update Date | 04/08/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5633 STRAND BLVD STE 307
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34110-7383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-777-2652
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3500 ISLANDWALK CIR
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34119-1614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-777-2652
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MA35566
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------