Healthcare Provider Details

I. General information

NPI: 1609668938
Provider Name (Legal Business Name): PERFORMANCE PELVIC MISSION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2025
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18131 HERON WALK DR
TAMPA FL
33647-3130
US

IV. Provider business mailing address

18131 HERON WALK DR
TAMPA FL
33647-3130
US

V. Phone/Fax

Practice location:
  • Phone: 813-838-1656
  • Fax:
Mailing address:
  • Phone: 813-838-1656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: FREDERICA O'DONNELL
Title or Position: OWNER
Credential: OTD, OTR/L
Phone: 813-838-1656