Provider Demographics
NPI:1225406846
Name:BROWN, RAYCHEL (PTA)
Entity Type:Individual
Prefix:
First Name:RAYCHEL
Middle Name:
Last Name:BROWN
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 1:12723 ALLEN ARCHER LN
Mailing Address - Street 2:
Mailing Address - City:THONOTOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:33592-2500
Mailing Address - Country:US
Mailing Address - Phone:813-400-7764
Mailing Address - Fax:
Practice Address - Street 1:11754 MARTIN LUTHER KING BLVD E
Practice Address - Street 2:
Practice Address - City:SEFFNER
Practice Address - State:FL
Practice Address - Zip Code:33584-4923
Practice Address - Country:US
Practice Address - Phone:813-661-8267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-14
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 25943225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant