Provider Demographics
NPI:1902091903
Name:DE GUZMAN, MA OLIVIA N (PT)
Entity Type:Individual
Prefix:
First Name:MA OLIVIA
Middle Name:N
Last Name:DE GUZMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 S PALM AVE
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-4148
Mailing Address - Country:US
Mailing Address - Phone:386-385-5499
Mailing Address - Fax:386-385-5498
Practice Address - Street 1:2200 KINGS HWY
Practice Address - Street 2:SUITE 2F
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33980-5759
Practice Address - Country:US
Practice Address - Phone:941-457-7775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT7844225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Y8615OtherBLUE CROSS BLUE SHIELD
Y8615OtherBLUE CROSS BLUE SHIELD