Healthcare Provider Details

I. General information

NPI: 1487896312
Provider Name (Legal Business Name): HEATHER AVERY PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2009
Last Update Date: 01/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 VONDERBURG DR SUITE 201
BRANDON FL
33511-5900
US

IV. Provider business mailing address

602 VONDERBURG DR SUITE 201
BRANDON FL
33511-5900
US

V. Phone/Fax

Practice location:
  • Phone: 813-653-1149
  • Fax: 813-654-6644
Mailing address:
  • Phone: 813-653-1149
  • Fax: 813-654-6644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number11760
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number1193767
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT27934
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: