=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538632062
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA MATULKA MA83905
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2019
-----------------------------------------------------
Last Update Date | 01/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3411 BONITA BEACH RD STE 305
-----------------------------------------------------
City | BONITA SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34134-4155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-529-7122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6020 JONATHANS BAY CIR APT 301
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33908-7255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-860-4959
-----------------------------------------------------
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 | MA83905
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------