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General NPI Number Information
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NPI Number | 1386809424
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Entity Type | Individual
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Provider Name | MARIELLE GRACE SHOFFSTALL LMT
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Gender | Female
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Dates
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Enumeration Date | 07/28/2008
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Last Update Date | 07/28/2008
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Provider Practice Location Address
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Address Line | 10401 US HIGHWAY 441 SUITE 326
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City | LEESBURG
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State | FL
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Zip | 34788-8787
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Country | US
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Telephone | 352-365-6155
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Fax |
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Provider Business Mailing Address
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Address Line | 10218 MISTY MEADOW RD
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City | LEESBURG
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State | FL
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Zip | 34788-3300
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Country | US
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Telephone | 352-617-5121
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MA48313
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License Number State | FL
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