Healthcare Provider Details

I. General information

NPI: 1649855750
Provider Name (Legal Business Name): FERNANDA GONCALVES CIVITELLA DPT, PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2021
Last Update Date: 03/10/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 NW 16TH ST RM 2C134
MIAMI FL
33125-1624
US

IV. Provider business mailing address

3204 BIRD AVE APT 115
MIAMI FL
33133-4462
US

V. Phone/Fax

Practice location:
  • Phone: 305-575-7000
  • Fax:
Mailing address:
  • Phone: 202-615-9828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT35291
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: