Healthcare Provider Details

I. General information

NPI: 1750737185
Provider Name (Legal Business Name): TYME MCCORMICK PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 05/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W GUAVA ST SUITES 204 & 205
LADY LAKE FL
32159-1701
US

IV. Provider business mailing address

4500 W NEWBERRY RD
GAINESVILLE FL
32607-2245
US

V. Phone/Fax

Practice location:
  • Phone: 352-633-7222
  • Fax:
Mailing address:
  • Phone: 352-336-6000
  • Fax: 352-336-6029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA26272
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: