Healthcare Provider Details

I. General information

NPI: 1851902514
Provider Name (Legal Business Name): THE GULFSIDE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2020
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13540 17TH STREET
DADE CITY FL
33525-5244
US

IV. Provider business mailing address

13540 17TH ST
DADE CITY FL
33525-5244
US

V. Phone/Fax

Practice location:
  • Phone: 352-437-5151
  • Fax: 813-212-3870
Mailing address:
  • Phone: 352-437-5151
  • Fax: 813-212-3870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: SUSANNE WITT
Title or Position: ADMIN MGR
Credential:
Phone: 352-585-7871