Healthcare Provider Details

I. General information

NPI: 1407118268
Provider Name (Legal Business Name): FLORIDA MOVEMENT THERAPY CENTER-BOCA RATON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2012
Last Update Date: 07/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21065 POWERLINE RD SUITE A2
BOCA RATON FL
33433-2313
US

IV. Provider business mailing address

21065 POWERLINE RD SUITE A2
BOCA RATON FL
33433-2313
US

V. Phone/Fax

Practice location:
  • Phone: 561-883-7800
  • Fax: 561-883-7801
Mailing address:
  • Phone: 561-883-7800
  • Fax: 561-883-7801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License NumberOT9734
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA5535
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License NumberPT3436
License Number StateFL

VIII. Authorized Official

Name: JODI GRAY
Title or Position: VICE PRESIDENT
Credential: PT
Phone: 561-883-7800