Healthcare Provider Details

I. General information

NPI: 1477132579
Provider Name (Legal Business Name): PROVIDENCE PEDIATRIC THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 09/11/2025
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7616 W COURTNEY CAMPBELL CSWY UNIT 210
TAMPA FL
33607-1533
US

IV. Provider business mailing address

7616 W COURTNEY CAMPBELL CSWY UNIT 210
TAMPA FL
33607-1533
US

V. Phone/Fax

Practice location:
  • Phone: 815-505-5545
  • Fax:
Mailing address:
  • Phone: 815-505-5545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MISS HANNAH NICOLE BERGE
Title or Position: OCCUPATIONAL THERAPIST
Credential: OTR/L
Phone: 815-505-5545