Provider Demographics
NPI:1477132579
Name:PROVIDENCE PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:PROVIDENCE PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:HANNAH
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:BERGE
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:815-505-5545
Mailing Address - Street 1:7616 W COURTNEY CAMPBELL CSWY UNIT 210
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-1533
Mailing Address - Country:US
Mailing Address - Phone:815-505-5545
Mailing Address - Fax:
Practice Address - Street 1:7616 W COURTNEY CAMPBELL CSWY UNIT 210
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-1533
Practice Address - Country:US
Practice Address - Phone:815-505-5545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOT20551Medicaid