Provider Demographics
NPI:1376631440
Name:LINE, JANET (MS, CCC)
Entity Type:Individual
Prefix:MRS
First Name:JANET
Middle Name:
Last Name:LINE
Suffix:
Gender:F
Credentials:MS, CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 VONDERBURG DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5900
Mailing Address - Country:US
Mailing Address - Phone:813-653-1149
Mailing Address - Fax:813-654-6644
Practice Address - Street 1:602 VONDERBURG DR
Practice Address - Street 2:SUITE 201
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5900
Practice Address - Country:US
Practice Address - Phone:813-653-1149
Practice Address - Fax:813-654-6644
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7365235Z00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL812017000Medicaid
FLS2706OtherBC/BS OF FLORIDA #
FL887959100Medicaid
FL887959100Medicaid