Healthcare Provider Details

I. General information

NPI: 1669303772
Provider Name (Legal Business Name): PROVIDENCE PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 OFFICE PARK DR STE B&C
BRANDON MS
39042-2403
US

IV. Provider business mailing address

109 OFFICE PARK DR STE B&C
BRANDON MS
39042-2403
US

V. Phone/Fax

Practice location:
  • Phone: 769-257-1416
  • Fax:
Mailing address:
  • Phone: 769-257-1416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: SYDNEY MARIE BEARDEN
Title or Position: OWNER
Credential: MS, BCBA, LBA
Phone: 769-257-1416