Provider Demographics
NPI:1114253382
Name:VISTA THERAPY SERVICES, PA
Entity Type:Organization
Organization Name:VISTA THERAPY SERVICES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MA,CCC-SLP
Authorized Official - Phone:727-504-6941
Mailing Address - Street 1:6634 79 AVE.
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33781
Mailing Address - Country:US
Mailing Address - Phone:727-504-6941
Mailing Address - Fax:
Practice Address - Street 1:6634 79 AVE.
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781
Practice Address - Country:US
Practice Address - Phone:727-504-6941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-23
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6805235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8887454Medicaid