Provider Demographics
NPI:1083785810
Name:INNOVATIVE CHILDREN'S THERAPY, INC
Entity Type:Organization
Organization Name:INNOVATIVE CHILDREN'S THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAYNA
Authorized Official - Middle Name:JILL
Authorized Official - Last Name:BRUNETTE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT
Authorized Official - Phone:407-679-7837
Mailing Address - Street 1:4819 FISKE CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32826-4278
Mailing Address - Country:US
Mailing Address - Phone:407-679-7837
Mailing Address - Fax:
Practice Address - Street 1:5423 LAKE HOWELL RD
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-1033
Practice Address - Country:US
Practice Address - Phone:407-679-7837
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2251P0200X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL890816800Medicaid