Healthcare Provider Details

I. General information

NPI: 1669040366
Provider Name (Legal Business Name): EXCELLERATED TEACHING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2021
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5175 45TH ST N
ST PETERSBURG FL
33714-2266
US

IV. Provider business mailing address

5175 45TH ST N
ST PETERSBURG FL
33714-2266
US

V. Phone/Fax

Practice location:
  • Phone: 727-748-4060
  • Fax: 727-748-4060
Mailing address:
  • Phone: 727-748-4060
  • Fax: 727-748-4060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROBERT JONES HASBROUCK
Title or Position: OWNER
Credential:
Phone: 727-748-4060