Provider Demographics
NPI:1942857511
Name:IMAGINE PEDIATRIC THERAPY OF BREVARD, LLC
Entity Type:Organization
Organization Name:IMAGINE PEDIATRIC THERAPY OF BREVARD, LLC
Other - Org Name:IMAGINE PEDIATRIC THERAPY, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:YELBA
Authorized Official - Middle Name:MERCEDES
Authorized Official - Last Name:DELGADO
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:321-223-8791
Mailing Address - Street 1:600 N SONORA CIR
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-3735
Mailing Address - Country:US
Mailing Address - Phone:321-223-8791
Mailing Address - Fax:321-373-8791
Practice Address - Street 1:600 N SONORA CIR
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-3735
Practice Address - Country:US
Practice Address - Phone:321-223-8791
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-19
Last Update Date:2021-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104044500Medicaid
FL110199500Medicaid