Provider Demographics
NPI:1679227508
Name:PEDIATRIC THERAPY OF ORMOND, LLC
Entity Type:Organization
Organization Name:PEDIATRIC THERAPY OF ORMOND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERI
Authorized Official - Middle Name:
Authorized Official - Last Name:ESSIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-871-0428
Mailing Address - Street 1:16 BLACK WATER WAY
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5706
Mailing Address - Country:US
Mailing Address - Phone:138-687-1042
Mailing Address - Fax:
Practice Address - Street 1:16 BLACK WATER WAY
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5706
Practice Address - Country:US
Practice Address - Phone:386-871-0428
Practice Address - Fax:386-463-8565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016451300Medicaid