Provider Demographics
NPI:1104364371
Name:POTITHAVORANANT, NED (DPT)
Entity Type:Individual
Prefix:
First Name:NED
Middle Name:
Last Name:POTITHAVORANANT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1528 LAKEVIEW RD STE 150
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-3648
Mailing Address - Country:US
Mailing Address - Phone:727-408-5222
Mailing Address - Fax:727-408-5252
Practice Address - Street 1:1528 LAKEVIEW RD STE 150
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3648
Practice Address - Country:US
Practice Address - Phone:727-408-5222
Practice Address - Fax:727-408-5252
Is Sole Proprietor?:No
Enumeration Date:2017-02-07
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1287828225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist