Provider Demographics
NPI:1821189911
Name:SCULLY, THERESA (PT)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:SCULLY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1837 W WINDY WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-1945
Mailing Address - Country:US
Mailing Address - Phone:904-860-5392
Mailing Address - Fax:
Practice Address - Street 1:1837 W WINDY WAY
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-1945
Practice Address - Country:US
Practice Address - Phone:904-860-5392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT18900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL887951600Medicaid