Healthcare Provider Details

I. General information

NPI: 1679767545
Provider Name (Legal Business Name): ETHEL L CROSBY EARLY INTERVENTION
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ETHEL L BISMARCK EARLY INTERVENTION

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5541 1ST AVE N
SAINT PETERSBURG FL
33710-8005
US

IV. Provider business mailing address

5541 1ST AVE N
SAINT PETERSBURG FL
33710-8005
US

V. Phone/Fax

Practice location:
  • Phone: 727-767-4403
  • Fax: 727-767-4715
Mailing address:
  • Phone: 727-767-4403
  • Fax: 727-767-4715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: