=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508539586
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMPRESSION HOME HEALTHCARE & THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2021
-----------------------------------------------------
Last Update Date | 08/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1701 N 14TH ST
-----------------------------------------------------
City | FORT PIERCE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34950-2113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-206-2289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6258 WAUCONDA WAY W
-----------------------------------------------------
City | LAKE WORTH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33463-5870
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-860-1339
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING DIRECTOR
-----------------------------------------------------
Name | ROSEGUENE STEPHEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-860-1339
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD1600X
-----------------------------------------------------
Taxonomy Name | Developmental Disabilities Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QX0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 2081P0010X
-----------------------------------------------------
Taxonomy Name | Pediatric Rehabilitation Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #10
-----------------------------------------------------
Taxonomy Code | 2081S0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #11
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #12
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------