Basic Information
| Provider Information | |||||||||
| NPI: | 1093929770 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF SOUTH FLORIDA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | USF CHILD DEVELOPMENT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13101 BRUCE B DOWNS BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336123803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139740601 | ||||||||
| FaxNumber: | 8135581340 | ||||||||
| Practice Location | |||||||||
| Address1: | 13101 BRUCE B DOWNS BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336123803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139740601 | ||||||||
| FaxNumber: | 8135581340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2007 | ||||||||
| LastUpdateDate: | 08/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | HAM | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8139740601 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 222Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
No ID Information.