Provider Demographics
NPI:1760946990
Name:RADIANT PEDIATRIC THERAPY, LLC
Entity Type:Organization
Organization Name:RADIANT PEDIATRIC THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:786-200-8222
Mailing Address - Street 1:10901 SW 102ND CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-3472
Mailing Address - Country:US
Mailing Address - Phone:786-200-8222
Mailing Address - Fax:786-913-5062
Practice Address - Street 1:10901 SW 102ND CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-3472
Practice Address - Country:US
Practice Address - Phone:786-200-8222
Practice Address - Fax:786-913-5062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-22
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004566900Medicaid