MEDICARE: INNOVATIVE CHILDREN'S THERAPY, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist		FL
2	2251P0200X	Pediatric Physical Therapist		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083785810
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE CHILDREN'S THERAPY, INC

Provider Business Mailing Address
First Line	:	4819 FISKE CIR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32826-4278
Country	:	US
Telephone Number	:	407-679-7837
Fax Number	:

Provider Business Practice Location Address
First Line	:	5423 LAKE HOWELL RD
Second Line	:
City	:	WINTER PARK
State	:	FL
Zip	:	32792-1033
Country	:	US
Telephone Number	:	407-679-7837
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. DAYNA JILL BRUNETTE
Credential	:	MS, PT
Telephone Number	:	407-679-7837

Provider Enumeration Date	:	11/13/2006
Last Update Date	:	01/24/2011

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