MEDICARE: MS. DIANE CHITWOOD PTA

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	225200000X	Physical Therapy Assistant	PTA29468	FL

General Provider Information

NPI Number	:	1730444357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DIANE CHITWOOD PTA

Provider Business Mailing Address
First Line	:	8477 S SUNCOAST BLVD
Second Line	:
City	:	HOMOSASSA
State	:	FL
Zip	:	34446-5028
Country	:	US
Telephone Number	:	352-382-7214
Fax Number	:	352-382-7781

Provider Business Practice Location Address
First Line	:	1537 NE CEDAR ST
Second Line	:
City	:	JENSEN BEACH
State	:	FL
Zip	:	34957-4808
Country	:	US
Telephone Number	:	772-208-5071
Fax Number	:	772-261-2108

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2012
Last Update Date	:	12/17/2019

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