Healthcare Provider Details

I. General information

NPI: 1326919002
Provider Name (Legal Business Name): MAKENZIE DIANA SOVERCOOL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2025
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13780 SE 100TH AVE
BELLEVIEW FL
34420-6955
US

IV. Provider business mailing address

324 N YORK ST
BUSHNELL FL
33513-5304
US

V. Phone/Fax

Practice location:
  • Phone: 352-789-0713
  • Fax:
Mailing address:
  • Phone: 352-801-4287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number33587
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: