Provider Demographics
NPI:1962684670
Name:TITHERINGTON, JUAN
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:TITHERINGTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5709 SEAGRAPE DR
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-3228
Mailing Address - Country:US
Mailing Address - Phone:772-464-9866
Mailing Address - Fax:
Practice Address - Street 1:1705 17TH AVE
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-3641
Practice Address - Country:US
Practice Address - Phone:772-562-6877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA18633225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant