Healthcare Provider Details

I. General information

NPI: 1538592977
Provider Name (Legal Business Name): 123 THERAPY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2013
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3670 N 54TH AVE
HOLLYWOOD FL
33021-2340
US

IV. Provider business mailing address

3670 N 54TH AVE
HOLLYWOOD FL
33021-2340
US

V. Phone/Fax

Practice location:
  • Phone: 305-651-9311
  • Fax: 754-201-1390
Mailing address:
  • Phone:
  • Fax: 754-201-1390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT21718
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA20109
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA19414
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA21752
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA22491
License Number StateFL
# 7
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA10823
License Number StateFL
# 8
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA11876
License Number StateFL

VIII. Authorized Official

Name: MARIANA TALARICO DE NOLASCO
Title or Position: PRESIDENT/OWNER
Credential: PT
Phone: 305-651-9311