Healthcare Provider Details

I. General information

NPI: 1629702717
Provider Name (Legal Business Name): PEDIATRIC NEURODEVELOPMENTAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2022
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3282 TOSCANA DR
SAINT CLOUD FL
34772-6710
US

IV. Provider business mailing address

3282 TOSCANA DR
SAINT CLOUD FL
34772-6710
US

V. Phone/Fax

Practice location:
  • Phone: 813-450-6128
  • Fax:
Mailing address:
  • Phone: 813-450-6128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. AVI ELIZABETH DOMNITZ-GEBET
Title or Position: PHYSICIAN
Credential: DO
Phone: 813-450-6128