Basic Information
| Provider Information | |||||||||
| NPI: | 1215160783 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERBERT | ||||||||
| FirstName: | THERESA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13101 BRUCE B DOWNS BLVD | ||||||||
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| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336123803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139740602 | ||||||||
| FaxNumber: | 8135581343 | ||||||||
| Practice Location | |||||||||
| Address1: | 13101 BRUCE B DOWNS BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336123803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139740602 | ||||||||
| FaxNumber: | 8135581343 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2009 | ||||||||
| LastUpdateDate: | 04/18/2017 | ||||||||
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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 | 235Z00000X | SZ4827 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 222Q00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
ID Information
| ID | Type | State | Issuer | Description | 001383800 | 05 | FL | MEDICAID | 001856500 | 05 | FL | MEDICAID |