Provider Demographics
NPI:1083980767
Name:FAVACHO, ANTONIA M (PTA)
Entity Type:Individual
Prefix:
First Name:ANTONIA
Middle Name:M
Last Name:FAVACHO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 MORTON PLANT STREET
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-0000
Mailing Address - Country:US
Mailing Address - Phone:727-841-8384
Mailing Address - Fax:727-461-8206
Practice Address - Street 1:430 MORTON PLANT ST
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3398
Practice Address - Country:US
Practice Address - Phone:727-841-8384
Practice Address - Fax:727-461-8206
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21770225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant