Healthcare Provider Details

I. General information

NPI: 1780350025
Provider Name (Legal Business Name): PICKY EATERS ONLINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2021
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5030 HARTWELL CT
SAINT CLOUD FL
34771-7936
US

IV. Provider business mailing address

5030 HARTWELL CT
SAINT CLOUD FL
34771-7936
US

V. Phone/Fax

Practice location:
  • Phone: 321-388-2924
  • Fax:
Mailing address:
  • Phone: 321-388-2924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KELLY KOMISARUK
Title or Position: PRESIDENT
Credential: M.ED, CCC-SLP
Phone: 321-388-2924