Provider Demographics
NPI:1104967116
Name:MYOFASCIAL THERAPY INC
Entity type:Organization
Organization Name:MYOFASCIAL THERAPY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:FELLENZ
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:239-592-6100
Mailing Address - Street 1:5691 NAPLES BLVD
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-2023
Mailing Address - Country:US
Mailing Address - Phone:239-592-6100
Mailing Address - Fax:239-592-6156
Practice Address - Street 1:5691 NAPLES BLVD
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-2023
Practice Address - Country:US
Practice Address - Phone:239-592-6100
Practice Address - Fax:239-592-6156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-11
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 7400225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL811167700Medicaid