Healthcare Provider Details

I. General information

NPI: 1053741256
Provider Name (Legal Business Name): DENISE BUSH OVERLOCK PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2013
Last Update Date: 09/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 6TH ST SE SUITE B
WINTER HAVEN FL
33880-4605
US

IV. Provider business mailing address

1490 AVENUE H NE
WINTER HAVEN FL
33881-4353
US

V. Phone/Fax

Practice location:
  • Phone: 863-294-0350
  • Fax: 863-294-0381
Mailing address:
  • Phone: 863-291-6414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA9272
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: