Provider Demographics
NPI:1689496234
Name:BURROUGHS, GINA (LMT)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:BURROUGHS
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 1:547 E NEW YORK AVE STE D
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-6081
Mailing Address - Country:US
Mailing Address - Phone:386-873-2431
Mailing Address - Fax:
Practice Address - Street 1:547 E NEW YORK AVE STE D
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-6081
Practice Address - Country:US
Practice Address - Phone:386-873-2431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-25
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty