Provider Demographics
NPI:1922506120
Name:DIRECT PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:DIRECT PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOCELYN
Authorized Official - Middle Name:BESA
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, CLT
Authorized Official - Phone:386-401-6100
Mailing Address - Street 1:1495 S VOLUSIA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-7047
Mailing Address - Country:US
Mailing Address - Phone:386-401-6100
Mailing Address - Fax:386-960-0551
Practice Address - Street 1:1495 S VOLUSIA AVE STE 101
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-7047
Practice Address - Country:US
Practice Address - Phone:386-401-6100
Practice Address - Fax:386-960-0551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-23
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT32520208100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty