MEDICARE: PEDIATRIC THERAPY OF ORMOND, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist
2	235Z00000X	Speech-Language Pathologist	SA 1622	FL
3	225100000X	Physical Therapist	PT 23030	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568646008
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC THERAPY OF ORMOND, LLC

Provider Business Mailing Address
First Line	:	16 BLACK WATER WAY
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-5706
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	16 BLACK WATER WAY
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-5706
Country	:	US
Telephone Number	:	386-871-0428
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PHYSICAL THERAPIST
Name	:	TERI ESSIG
Credential	:	MPT
Telephone Number	:	386-871-0428

Provider Enumeration Date	:	12/19/2007
Last Update Date	:	02/09/2022

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