MEDICARE: ENLIGHTENED THERAPIES

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	235Z00000X	Speech-Language Pathologist	SA6674	FL

General Provider Information

NPI Number	:	1417384926
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENLIGHTENED THERAPIES

Provider Business Mailing Address
First Line	:	14454 BASILHAM LN
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-4423
Country	:	US
Telephone Number	:	904-571-5230
Fax Number	:	904-571-5230

Provider Business Practice Location Address
First Line	:	14454 BASILHAM LN
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-4423
Country	:	US
Telephone Number	:	904-571-5230
Fax Number	:	904-571-5230

Authorized Official
Title or Position	:	OWNER
Name	:	AMY THOMAS
Credential	:
Telephone Number	:	904-571-5230

Provider Enumeration Date	:	09/28/2013
Last Update Date	:	09/28/2013

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Directions to “ENLIGHTENED THERAPIES ” Practice Location

Language	Start Address	Practice Location

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