Healthcare Provider Details

I. General information

NPI: 1740945674
Provider Name (Legal Business Name): BOLD CHILD CO.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2021
Last Update Date: 11/04/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14444 BEACH BLVD STE 28
JACKSONVILLE FL
32250-2080
US

IV. Provider business mailing address

12951 THE WOODS DR S
JACKSONVILLE FL
32246-1165
US

V. Phone/Fax

Practice location:
  • Phone: 904-210-0332
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. KATE DEVALERIO
Title or Position: CO-OWNER, PHYSICAL THERAPIST
Credential: PT, DPT, PCS
Phone: 904-210-0332