Healthcare Provider Details

I. General information

NPI: 1922681436
Provider Name (Legal Business Name): DANIEL REDLIEN PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 05/03/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1990 W NEW HAVEN AVE STE 105
MELBOURNE FL
32904-3908
US

IV. Provider business mailing address

1990 W NEW HAVEN AVE STE 105
MELBOURNE FL
32904-3908
US

V. Phone/Fax

Practice location:
  • Phone: 321-768-6119
  • Fax:
Mailing address:
  • Phone: 321-768-6119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA30601
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: