Provider Demographics
NPI:1558077370
Name:IMMERSED PEDIATRIC THERAPY LLC
Entity Type:Organization
Organization Name:IMMERSED PEDIATRIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:AJA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MS, ORT/L
Authorized Official - Phone:904-304-0434
Mailing Address - Street 1:2424 W BRANDON BLVD # 1023
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4717
Mailing Address - Country:US
Mailing Address - Phone:813-400-3265
Mailing Address - Fax:
Practice Address - Street 1:6915 SURREY OAK DR
Practice Address - Street 2:
Practice Address - City:APOLLO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33572-1531
Practice Address - Country:US
Practice Address - Phone:813-400-3265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty