Healthcare Provider Details

I. General information

NPI: 1568646008
Provider Name (Legal Business Name): PEDIATRIC THERAPY OF ORMOND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 BLACK WATER WAY
ORMOND BEACH FL
32174-5706
US

IV. Provider business mailing address

16 BLACK WATER WAY
ORMOND BEACH FL
32174-5706
US

V. Phone/Fax

Practice location:
  • Phone: 386-871-0428
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 23030
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA 1622
License Number StateFL

VIII. Authorized Official

Name: TERI ESSIG
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: MPT
Phone: 386-871-0428