Basic Information
| Provider Information | |||||||||
| NPI: | 1467028456 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUNCOAST THERAPY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 631278 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452631278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414850121 | ||||||||
| FaxNumber: | 9414850519 | ||||||||
| Practice Location | |||||||||
| Address1: | 11910 BOYETTE RD | ||||||||
| Address2: | |||||||||
| City: | RIVERVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335695601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414850121 | ||||||||
| FaxNumber: | 9414850519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2021 | ||||||||
| LastUpdateDate: | 06/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | WILDERMUTH | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9414850121 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | SLP | ||||||||
| NPICertificationDate: | 06/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103K00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 224Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.