Provider Demographics
NPI:1306627203
Name:FIOTODIMITRAKIS, THEODORA (LMT, CHHC)
Entity type:Individual
Prefix:
First Name:THEODORA
Middle Name:
Last Name:FIOTODIMITRAKIS
Suffix:
Gender:F
Credentials:LMT, CHHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 DITMARS BLVD
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-3417
Mailing Address - Country:US
Mailing Address - Phone:646-359-2498
Mailing Address - Fax:
Practice Address - Street 1:2178 21ST ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-3618
Practice Address - Country:US
Practice Address - Phone:646-504-2112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171400000X
NY033056225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171400000XOther Service ProvidersHealth & Wellness Coach