Provider Demographics
NPI:1467857755
Name:REDDY, TIM (PTA)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:REDDY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-6869
Mailing Address - Country:US
Mailing Address - Phone:386-843-3298
Mailing Address - Fax:
Practice Address - Street 1:1200 LEXINGTON GREEN LN
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1013
Practice Address - Country:US
Practice Address - Phone:407-688-0070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-29
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA25319225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant