Provider Demographics
NPI:1912459629
Name:PROGRESSIVE PEDIATRIC THERAPY SERVICES EARLY INTERVENTION
Entity type:Organization
Organization Name:PROGRESSIVE PEDIATRIC THERAPY SERVICES EARLY INTERVENTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:QUIN
Authorized Official - Last Name:PREJEAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:850-325-6301
Mailing Address - Street 1:1725 HERMITAGE BLVD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-7709
Mailing Address - Country:US
Mailing Address - Phone:850-325-6301
Mailing Address - Fax:850-325-6302
Practice Address - Street 1:1725 HERMITAGE BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-7709
Practice Address - Country:US
Practice Address - Phone:850-325-6301
Practice Address - Fax:850-325-6302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-28
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003247800Medicaid