Provider Demographics
NPI:1619218054
Name:PROGRESSIVE PEDIATRIC THERAPY SERVICES
Entity Type:Organization
Organization Name:PROGRESSIVE PEDIATRIC THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:850-524-2048
Mailing Address - Street 1:2005 SANDCASTLE DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4864
Mailing Address - Country:US
Mailing Address - Phone:904-226-8890
Mailing Address - Fax:
Practice Address - Street 1:2005 SANDCASTLE DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4864
Practice Address - Country:US
Practice Address - Phone:904-226-8890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROGRESSIVE PEDIATRIC DEVELOPMENTAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-11
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12786252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$OtherSOCIAL SECURITY