Basic Information
| Provider Information | |||||||||
| NPI: | 1891034625 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PLAY FOR REAL THERAPY SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1535 COGSWELL ST STE C24 | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329552740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218728737 | ||||||||
| FaxNumber: | 3219780336 | ||||||||
| Practice Location | |||||||||
| Address1: | 1535 COGSWELL ST STE C24 | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329552740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218728737 | ||||||||
| FaxNumber: | 3219780336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2013 | ||||||||
| LastUpdateDate: | 03/09/2016 | ||||||||
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| AuthorizedOfficialLastName: | BENNETT | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3218728737 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | OTD, OTR/L | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.