Provider Demographics
NPI:1104669704
Name:ALLEN, WILLIAM S JR (LMT)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:S
Last Name:ALLEN
Suffix:JR
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5005 SPEARMINT ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-5953
Mailing Address - Country:US
Mailing Address - Phone:352-283-5864
Mailing Address - Fax:
Practice Address - Street 1:179 COLLEGE DR STE 16
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-7690
Practice Address - Country:US
Practice Address - Phone:352-283-5864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL100828225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty