Provider Demographics
NPI:1619020674
Name:RAYMOND, RENUKA (PT)
Entity Type:Individual
Prefix:MRS
First Name:RENUKA
Middle Name:
Last Name:RAYMOND
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2506 ACORN ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34947-4750
Mailing Address - Country:US
Mailing Address - Phone:772-595-5200
Mailing Address - Fax:772-595-5250
Practice Address - Street 1:2506 ACORN ST
Practice Address - Street 2:SUITE D
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34947-4750
Practice Address - Country:US
Practice Address - Phone:772-595-5200
Practice Address - Fax:772-595-5250
Is Sole Proprietor?:No
Enumeration Date:2007-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 10514225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist