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General NPI Number Information
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NPI Number | 1114654431
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Entity Type | Organization
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Legal Business Name | BLUE TIDE PEDIATRIC THERAPY LLC
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Dates
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Enumeration Date | 08/05/2022
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Last Update Date | 01/13/2025
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Provider Practice Location Address
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Address Line | 4641 GULFSTARR DR STE 102
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City | DESTIN
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State | FL
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Zip | 32541-3776
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Country | US
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Telephone | 850-964-6162
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Fax | 850-848-6643
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Provider Business Mailing Address
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Address Line | 4641 GULFSTARR DR STE 102
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City | DESTIN
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State | FL
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Zip | 32541-3776
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/SPEECH-LANGUAGE PATHOLOGIST
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Name | GARRETT OUTLAND
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Credential | MA, CCC-SLP
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Telephone | 850-964-6162
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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