Provider Demographics
NPI:1750449567
Name:ISENBERG PEDIATRIC OCCUP THERAPY INC
Entity Type:Organization
Organization Name:ISENBERG PEDIATRIC OCCUP THERAPY INC
Other - Org Name:UNITED THERAPY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:ISENBERG
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OTRL
Authorized Official - Phone:850-258-6366
Mailing Address - Street 1:PO BOX 568
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444
Mailing Address - Country:US
Mailing Address - Phone:850-258-6366
Mailing Address - Fax:850-522-8022
Practice Address - Street 1:2685 JENKS AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4351
Practice Address - Country:US
Practice Address - Phone:850-215-6788
Practice Address - Fax:850-215-6787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT2238225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL886362800Medicaid