Provider Demographics
NPI:1124486949
Name:THERAPY CONNECTION OF THE TREASURE COAST
Entity type:Organization
Organization Name:THERAPY CONNECTION OF THE TREASURE COAST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUSTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:THEISEN
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC-SLP
Authorized Official - Phone:772-301-1207
Mailing Address - Street 1:549 NW LAKE WHITNEY PL STE 104
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1606
Mailing Address - Country:US
Mailing Address - Phone:772-301-1207
Mailing Address - Fax:772-301-1255
Practice Address - Street 1:549 NW LAKE WHITNEY PL STE 104
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986
Practice Address - Country:US
Practice Address - Phone:772-301-1207
Practice Address - Fax:772-301-1255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-08
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA10918235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017281400Medicaid