Healthcare Provider Details

I. General information

NPI: 1992388094
Provider Name (Legal Business Name): SHAYLA MICHELLE ROUTH PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2021
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 E OAK ST
ARCADIA FL
34266-8902
US

IV. Provider business mailing address

6114 56TH TER E
BRADENTON FL
34203-9752
US

V. Phone/Fax

Practice location:
  • Phone: 863-491-7055
  • Fax: 863-491-7056
Mailing address:
  • Phone: 630-200-4351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number29599
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: