Healthcare Provider Details

I. General information

NPI: 1740430958
Provider Name (Legal Business Name): THERAPY DIRECT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2008
Last Update Date: 09/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 SPARROW BRACH CIRCLE
ST JOHNS FL
32259
US

IV. Provider business mailing address

470 SPARROW BRACH CIRCLE
ST JOHNS FL
32259
US

V. Phone/Fax

Practice location:
  • Phone: 904-525-0635
  • Fax: 904-287-2492
Mailing address:
  • Phone: 904-525-0635
  • Fax: 904-287-2492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT9465
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT11540
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA8670
License Number StateFL

VIII. Authorized Official

Name: MR. NOEL NOSSE
Title or Position: OWNER
Credential: OTR/L
Phone: 904-525-0635