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NPI Code Detail

MEDICARE: IMPACT THERAPY, LLC

MEDICARE: IMPACT THERAPY, LLC
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
1103K00000XBehavior Analyst

General Provider Information

NPI Number : 1639749674
Entity Type Code : Organization
Provider Name (Legal Business Name) : IMPACT THERAPY, LLC
Provider Business Mailing Address
First Line : 1717 HERMITAGE BLVD
Second Line :
City : TALLAHASSEE
State : FL
Zip : 32308-7709
Country : US
Telephone Number : 850-325-6301
Fax Number :
Provider Business Practice Location Address
First Line : 1717 HERMITAGE BLVD
Second Line :
City : TALLAHASSEE
State : FL
Zip : 32308-7709
Country : US
Telephone Number : 850-325-6301
Fax Number : 850-325-6302
Authorized Official
Title or Position : CLINIC DIRECTOR
Name : KELLY QUIN PREJEAN
Credential : MA, CCC-SLP
Telephone Number : 850-325-6301
Provider Enumeration Date : 07/01/2021
Last Update Date : 06/26/2024

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Directions to “IMPACT THERAPY, LLC ” Practice Location

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