Provider Demographics
NPI:1588056683
Name:MATHEOS, GERELLA (ITDS)
Entity type:Individual
Prefix:
First Name:GERELLA
Middle Name:
Last Name:MATHEOS
Suffix:
Gender:F
Credentials:ITDS
Other - Prefix:
Other - First Name:GERELLA
Other - Middle Name:
Other - Last Name:KENNISTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891
Mailing Address - Country:US
Mailing Address - Phone:813-974-0602
Mailing Address - Fax:
Practice Address - Street 1:13101 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-3803
Practice Address - Country:US
Practice Address - Phone:813-974-2201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-26
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014728000Medicaid