Healthcare Provider Details

I. General information

NPI: 1316421456
Provider Name (Legal Business Name): SPECIAL KIDS INNOVATION PROGRAM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 AVENUE B SE
WINTER HAVEN FL
33880-3037
US

IV. Provider business mailing address

150 AVENUE B SE
WINTER HAVEN FL
33880-3037
US

V. Phone/Fax

Practice location:
  • Phone: 863-294-1429
  • Fax: 863-298-0299
Mailing address:
  • Phone: 863-294-1429
  • Fax: 863-298-0299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: SHARON COMKOWYCZ
Title or Position: EXECUTIVE DIRECTOR
Credential: MS CCC-SLP
Phone: 863-294-1429