Provider Demographics
NPI:1104163245
Name:GAINES, LORI BODEN (LMT)
Entity type:Individual
Prefix:MS
First Name:LORI
Middle Name:BODEN
Last Name:GAINES
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5603 NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-8420
Mailing Address - Country:US
Mailing Address - Phone:941-587-5030
Mailing Address - Fax:
Practice Address - Street 1:2800 BAHIA VISTA ST STE 400
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2710
Practice Address - Country:US
Practice Address - Phone:941-587-5030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA35911225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist