Provider Demographics
NPI:1063887701
Name:MOOS, SHANA (MASSAGE THERAPIST)
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:MOOS
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 NEW JERSEY AVE
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-2046
Mailing Address - Country:US
Mailing Address - Phone:850-200-3376
Mailing Address - Fax:
Practice Address - Street 1:3003 S HIGHWAY 77 STE D
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-5627
Practice Address - Country:US
Practice Address - Phone:850-200-3376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-07
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 79633225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBC 090 BS590OtherFLORIDA BLUE