=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770711426
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AVERY D HORGAN PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2009
-----------------------------------------------------
Last Update Date | 05/22/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8101 SOUTHSIDE BLVD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32256-8067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-928-1133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 204 OLEANDER ST
-----------------------------------------------------
City | NEPTUNE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32266-4850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-335-8824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 008570
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 2305207540
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 28140
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------