Provider Demographics
NPI:1205115763
Name:PEDIATRIC THERAPY GROUP SERVICES
Entity type:Organization
Organization Name:PEDIATRIC THERAPY GROUP SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:PICKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:1843-270-7022
Mailing Address - Street 1:4440 26TH ST W
Mailing Address - Street 2:STE B
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34207-1201
Mailing Address - Country:US
Mailing Address - Phone:941-752-0408
Mailing Address - Fax:941-870-0876
Practice Address - Street 1:4440 26TH ST W
Practice Address - Street 2:STE B
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-1201
Practice Address - Country:US
Practice Address - Phone:941-752-0408
Practice Address - Fax:941-870-0876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-15
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT259672251P0200X
FLOT11414225XP0200X
FLOT12006225XP0200X
FLSA7026235Z00000X
252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004007400Medicaid
FL004007401Medicaid