Provider Demographics
NPI:1477008407
Name:METAMORPHOSIS THERAPY LLC
Entity Type:Organization
Organization Name:METAMORPHOSIS THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGETT
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:DIMANT
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:407-285-7907
Mailing Address - Street 1:13750 W COLONIAL DR STE 350-121
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-4204
Mailing Address - Country:US
Mailing Address - Phone:407-395-9976
Mailing Address - Fax:407-992-9368
Practice Address - Street 1:1450 DANIELS RD
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-4376
Practice Address - Country:US
Practice Address - Phone:407-395-9976
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-19
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017434700Medicaid
FL017434700Medicaid