Healthcare Provider Details

I. General information

NPI: 1013783711
Provider Name (Legal Business Name): 850 THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2023
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 JOHN KING RD
CRESTVIEW FL
32539-8306
US

IV. Provider business mailing address

124 JOHN KING RD
CRESTVIEW FL
32539-8306
US

V. Phone/Fax

Practice location:
  • Phone: 850-634-6020
  • Fax:
Mailing address:
  • Phone: 850-634-6020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: GABRIELLE BROOKS-GRIFFITH
Title or Position: PRESIDENT
Credential:
Phone: 850-634-6020