Provider Demographics
NPI:1558075853
Name:GOVEA, RANDY (PTA)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:GOVEA
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 1:8509 S FEDERAL HWY # US1
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-3346
Mailing Address - Country:US
Mailing Address - Phone:772-380-4549
Mailing Address - Fax:772-210-8920
Practice Address - Street 1:8509 S FEDERAL HWY # US1
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-3346
Practice Address - Country:US
Practice Address - Phone:772-380-4549
Practice Address - Fax:772-210-8920
Is Sole Proprietor?:No
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA27835225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant