=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356117014
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATHWAY PHYSICAL THERAPY AND WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2023
-----------------------------------------------------
Last Update Date | 12/04/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1975 E SUNRISE BLVD STE 801
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33304-1407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-344-9951
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7750 TEXAS TRL
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33487-1424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-344-9951
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICAL THERAPIST
-----------------------------------------------------
Name | MS. JESSICA JOY LOCKETT
-----------------------------------------------------
Credential | MSPT
-----------------------------------------------------
Telephone | 561-344-9951
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------