Provider Demographics
NPI:1679767545
Name:CROSBY, ETHEL L (EARLY INTERVENTION)
Entity Type:Individual
Prefix:MS
First Name:ETHEL
Middle Name:L
Last Name:CROSBY
Suffix:
Gender:F
Credentials:EARLY INTERVENTION
Other - Prefix:MRS
Other - First Name:ETHEL
Other - Middle Name:L
Other - Last Name:BISMARCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EARLY INTERVENTION
Mailing Address - Street 1:5541 1ST AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-8005
Mailing Address - Country:US
Mailing Address - Phone:727-767-4403
Mailing Address - Fax:727-767-4715
Practice Address - Street 1:5541 1ST AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-8005
Practice Address - Country:US
Practice Address - Phone:727-767-4403
Practice Address - Fax:727-767-4715
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL812163000Medicaid