Provider Demographics
NPI:1457789596
Name:LIFEFORCE PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:LIFEFORCE PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ESSE
Authorized Official - Suffix:
Authorized Official - Credentials:MHM, OTR/L
Authorized Official - Phone:586-206-0837
Mailing Address - Street 1:337 SW CHERRYHILL RD
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-6235
Mailing Address - Country:US
Mailing Address - Phone:586-206-0837
Mailing Address - Fax:
Practice Address - Street 1:337 SW CHERRYHILL RD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-6235
Practice Address - Country:US
Practice Address - Phone:586-206-0837
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12838225X00000X
MI5201004005225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1417258021Medicaid