Provider Demographics
NPI:1538768049
Name:BETHELMIE, DESIREE MONIQUE (LMT)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:MONIQUE
Last Name:BETHELMIE
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 1:1608 S CRYSTAL LAKE DR APT 54
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-3358
Mailing Address - Country:US
Mailing Address - Phone:407-219-2793
Mailing Address - Fax:
Practice Address - Street 1:1608 S CRYSTAL LAKE DR APT 54
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-3358
Practice Address - Country:US
Practice Address - Phone:407-219-2793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA92425225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist