Basic Information
Provider Information | |||||||||
NPI: | 1013135169 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THERAPEUTIC POTENTIALS, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6977 PROFESSIONAL PKWY E | ||||||||
Address2: |   | ||||||||
City: | LAKEWOOD RANCH | ||||||||
State: | FL | ||||||||
PostalCode: | 342408411 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9417583140 | ||||||||
FaxNumber: | 9418704891 | ||||||||
Practice Location | |||||||||
Address1: | 6977 PROFESSIONAL PKWY E | ||||||||
Address2: |   | ||||||||
City: | LAKEWOOD RANCH | ||||||||
State: | FL | ||||||||
PostalCode: | 342408411 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9417583140 | ||||||||
FaxNumber: | 9418704891 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/23/2007 | ||||||||
LastUpdateDate: | 08/21/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COLOMBO | ||||||||
AuthorizedOfficialFirstName: | RAY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 9417583140 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA5010 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
ID Information
ID | Type | State | Issuer | Description | 888464100 | 05 | FL |   | MEDICAID |