Provider Demographics
NPI:1073913893
Name:PEDIATRIC THERAPIES OF NORTHWEST FLORIDA, LLC
Entity Type:Organization
Organization Name:PEDIATRIC THERAPIES OF NORTHWEST FLORIDA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:STEVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-260-9016
Mailing Address - Street 1:7840 LILAC LN
Mailing Address - Street 2:APT 508
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-7668
Mailing Address - Country:US
Mailing Address - Phone:850-260-9016
Mailing Address - Fax:850-912-8561
Practice Address - Street 1:7840 LILAC LN
Practice Address - Street 2:APT 508
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-7668
Practice Address - Country:US
Practice Address - Phone:850-260-9016
Practice Address - Fax:850-912-8561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-28
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health