Provider Demographics
NPI:1740330968
Name:SUMMERS, EILEEN W
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:W
Last Name:SUMMERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1028 CANDLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2805
Mailing Address - Country:US
Mailing Address - Phone:863-294-1429
Mailing Address - Fax:863-298-0299
Practice Address - Street 1:6508 GUNN HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-4022
Practice Address - Country:US
Practice Address - Phone:813-963-6923
Practice Address - Fax:813-264-0768
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT201992251P0200X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL889152400Medicaid