Provider Demographics
NPI:1508917758
Name:DE FREITAS, NADINE ROSE (PT, DPT, ATC)
Entity Type:Individual
Prefix:MS
First Name:NADINE
Middle Name:ROSE
Last Name:DE FREITAS
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:MRS
Other - First Name:NADINE
Other - Middle Name:ROSE
Other - Last Name:QUEEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, ATC
Mailing Address - Street 1:4209 GROVEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-5914
Mailing Address - Country:US
Mailing Address - Phone:321-385-1599
Mailing Address - Fax:
Practice Address - Street 1:220 N SYKES CREEK PKWY STE 200
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-3490
Practice Address - Country:US
Practice Address - Phone:321-456-5214
Practice Address - Fax:321-521-1152
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT105582251S0007X, 225100000X
FLAL3832255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer