Provider Demographics
NPI:1154450096
Name:KID PRO THERAPY - BOAS CENTER
Entity Type:Organization
Organization Name:KID PRO THERAPY - BOAS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LORRAINNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP, PHD
Authorized Official - Phone:813-964-8481
Mailing Address - Street 1:16546 N DALE MABRY HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-1325
Mailing Address - Country:US
Mailing Address - Phone:813-964-8481
Mailing Address - Fax:813-964-8431
Practice Address - Street 1:16546 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-1325
Practice Address - Country:US
Practice Address - Phone:813-964-8481
Practice Address - Fax:813-964-8431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7752251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL889948700Medicaid