Provider Demographics
NPI:1942519103
Name:METAMORPHOSIS THERAPY, LLC
Entity Type:Organization
Organization Name:METAMORPHOSIS THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRIDGETT
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:DIMANT
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:407-285-7907
Mailing Address - Street 1:13750 W COLONIAL DR STE 350-121
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-4204
Mailing Address - Country:US
Mailing Address - Phone:407-395-9976
Mailing Address - Fax:407-992-9368
Practice Address - Street 1:301 S TUBB ST STE A-1
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:FL
Practice Address - Zip Code:34760
Practice Address - Country:US
Practice Address - Phone:407-395-9976
Practice Address - Fax:407-992-9368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-05
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL017434700103K00000X
225100000X, 2251P0200X, 225X00000X, 225XF0002X, 252Y00000X, 261QM1300X
FLSA 9096235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225XF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistFeeding, Eating & SwallowingGroup - Multi-Specialty
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002986300Medicaid