Basic Information
| Provider Information | |||||||||
| NPI: | 1174700199 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOUSEL | ||||||||
| FirstName: | BEVERLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 10TH AVE W | ||||||||
| Address2: | |||||||||
| City: | PALMETTO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342215032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417223582 | ||||||||
| FaxNumber: | 9417298322 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 10TH AVE W | ||||||||
| Address2: | |||||||||
| City: | PALMETTO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342215032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417223582 | ||||||||
| FaxNumber: | 9417208322 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2008 | ||||||||
| LastUpdateDate: | 01/12/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT24589 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 001622100 | 05 | FL | MEDICAID | 000813500 | 05 | FL | MEDICAID |