Healthcare Provider Details

I. General information

NPI: 1376631747
Provider Name (Legal Business Name): EASTERSEALS NORTHEAST CENTRAL FLORIDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 05/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1219 DUNN AVE
DAYTONA BEACH FL
32114
US

IV. Provider business mailing address

1219 DUNN AVE
DAYTONA BEACH FL
32114-2405
US

V. Phone/Fax

Practice location:
  • Phone: 386-255-4568
  • Fax: 386-258-7677
Mailing address:
  • Phone: 386-255-4568
  • Fax: 386-258-7677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT 14797
License Number StateFL

VIII. Authorized Official

Name: MS. BEVERLY JOHNSON
Title or Position: CEO (PRESIDENT)
Credential:
Phone: 386-255-4568