Healthcare Provider Details

I. General information

NPI: 1063753572
Provider Name (Legal Business Name): EARLY INTERVENTION SPECIALISTS OF NORTHWEST FLORIDA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2013
Last Update Date: 03/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5170 12TH AVE
MALONE FL
32445-3426
US

IV. Provider business mailing address

5170 12TH AVE
MALONE FL
32445-3426
US

V. Phone/Fax

Practice location:
  • Phone: 850-209-5880
  • Fax: 866-521-4620
Mailing address:
  • Phone: 850-209-5880
  • Fax: 866-521-4620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License NumberRN3076242
License Number StateFL

VIII. Authorized Official

Name: MARCIA S THOMPSON
Title or Position: OWNER
Credential: RN
Phone: 850-209-5880