Provider Demographics
NPI:1366833543
Name:PERALTA, DENISE
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:PERALTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 352530
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32135-2530
Mailing Address - Country:US
Mailing Address - Phone:800-796-0923
Mailing Address - Fax:800-796-0926
Practice Address - Street 1:25 PINE CONE DR
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-8423
Practice Address - Country:US
Practice Address - Phone:800-796-0923
Practice Address - Fax:800-796-0926
Is Sole Proprietor?:No
Enumeration Date:2015-02-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1402547225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant