Provider Demographics
NPI:1336020759
Name:EPHRAIM, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:EPHRAIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1763 NW SAINT LUCIE WEST BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-2501
Mailing Address - Country:US
Mailing Address - Phone:772-867-0544
Mailing Address - Fax:
Practice Address - Street 1:1763 NW SAINT LUCIE WEST BLVD STE 107
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2501
Practice Address - Country:US
Practice Address - Phone:772-867-0544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-11
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA73850225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty