Healthcare Provider Details

I. General information

NPI: 1417590431
Provider Name (Legal Business Name): ARTISTIC THERAPLAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2019
Last Update Date: 03/29/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3631 HAVENDALE BLVD STE C
AUBURNDALE FL
33823-4605
US

IV. Provider business mailing address

101 BRIGHTON WAY
AUBURNDALE FL
33823-2161
US

V. Phone/Fax

Practice location:
  • Phone: 863-651-7516
  • Fax:
Mailing address:
  • Phone: 863-651-7516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: AMANDA MARIA VENTURA
Title or Position: CEO
Credential: COTA
Phone: 863-651-7516