Basic Information
Provider Information
NPI: 1003144155
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: INNOCENT
FirstName: ELEANOR
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: DPT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
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OtherMiddleName:  
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OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 8517 SEA HARBOUR LN
Address2: APT #306
City: TEMPLE TERRACE
State: FL
PostalCode: 336371045
CountryCode: US
TelephoneNumber: 9042331975
FaxNumber:  
Practice Location
Address1: 3100 E FLETCHER AVE
Address2:  
City: TAMPA
State: FL
PostalCode: 336134613
CountryCode: US
TelephoneNumber: 8136157200
FaxNumber:  
Other Information
ProviderEnumerationDate: 12/01/2009
LastUpdateDate: 02/05/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000XPT25935FLN Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 
225100000X032186NYY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

No ID Information.


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