=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467920249
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOME SWEET HOME PEDIATRIC THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2018
-----------------------------------------------------
Last Update Date | 11/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11246 SW OLMSTEAD DR
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34987-1945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-579-5619
-----------------------------------------------------
Fax | 772-673-0523
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11246 SW OLMSTEAD DR
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34987-1945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-579-5619
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST/ OWNER
-----------------------------------------------------
Name | ANGELA SUEE LEE
-----------------------------------------------------
Credential | MS, PT
-----------------------------------------------------
Telephone | 954-579-5619
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251P0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------