Healthcare Provider Details

I. General information

NPI: 1306305891
Provider Name (Legal Business Name): LEAP OF FAITH ACRES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2019
Last Update Date: 03/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14315 FAMILY TRL
HUDSON FL
34669-3643
US

IV. Provider business mailing address

14315 FAMILY TRL
HUDSON FL
34669-3643
US

V. Phone/Fax

Practice location:
  • Phone: 727-389-3056
  • Fax:
Mailing address:
  • Phone: 727-389-3056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER SHADE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 727-389-3056