Healthcare Provider Details

I. General information

NPI: 1477851780
Provider Name (Legal Business Name): STEPHANIE L GOAR ITDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2011
Last Update Date: 03/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 W BUSCH BLVD SUITE 916
TAMPA FL
33618-4523
US

IV. Provider business mailing address

2901 W BUSCH BLVD SUITE 916
TAMPA FL
33618-4523
US

V. Phone/Fax

Practice location:
  • Phone: 813-748-1386
  • Fax:
Mailing address:
  • Phone: 813-748-1386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number222Q00000X
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: