Provider Demographics
NPI:1386754166
Name:BELLISSIMO, MICHELE ROSE (LMT)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:ROSE
Last Name:BELLISSIMO
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 1:30 AZALEA DR
Mailing Address - Street 2:
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33404-3041
Mailing Address - Country:US
Mailing Address - Phone:561-882-4214
Mailing Address - Fax:
Practice Address - Street 1:3375 BURNS RD
Practice Address - Street 2:STE. #104
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-4349
Practice Address - Country:US
Practice Address - Phone:561-624-1719
Practice Address - Fax:561-625-0768
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA47294174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA47294OtherMASSAGE THERAPY LICENSE