=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851072995
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAKEEM STEVEN HENRY LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2023
-----------------------------------------------------
Last Update Date | 07/31/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2222 FLAGLER PROMENADE WAY APT 301
-----------------------------------------------------
City | MAITLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32751-8720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-438-5301
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2417 CHADWICK CT
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32818-4745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | MA97087
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------