Provider Demographics
NPI:1891886750
Name:REARDON, DEBRA C (PT)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:C
Last Name:REARDON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4406 S FLORIDA AVE
Mailing Address - Street 2:SUITE 16
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2172
Mailing Address - Country:US
Mailing Address - Phone:863-648-0099
Mailing Address - Fax:863-709-9740
Practice Address - Street 1:4406 S FLORIDA AVE
Practice Address - Street 2:SUITE 16
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2172
Practice Address - Country:US
Practice Address - Phone:863-648-0099
Practice Address - Fax:863-709-9740
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT0005406225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAD029Medicare PIN