=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619218054
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROGRESSIVE PEDIATRIC THERAPY SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2013
-----------------------------------------------------
Last Update Date | 05/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2005 SANDCASTLE DR
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32308-4864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-226-8890
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2005 SANDCASTLE DR
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32308-4864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-226-8890
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MRS. TAMMY MCKENZIE
-----------------------------------------------------
Credential | OTR/L
-----------------------------------------------------
Telephone | 850-524-2048
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | 12786
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------