Provider Demographics
NPI:1902670789
Name:HIGH TIDE PEDIACTRIC THERAPY LLC
Entity Type:Organization
Organization Name:HIGH TIDE PEDIACTRIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:JO-ANN
Authorized Official - Last Name:CEREMUGA
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:814-282-7499
Mailing Address - Street 1:3909 SAWMILL CT
Mailing Address - Street 2:
Mailing Address - City:AWENDAW
Mailing Address - State:SC
Mailing Address - Zip Code:29429-5704
Mailing Address - Country:US
Mailing Address - Phone:814-282-7499
Mailing Address - Fax:
Practice Address - Street 1:3909 SAWMILL CT
Practice Address - Street 2:
Practice Address - City:AWENDAW
Practice Address - State:SC
Practice Address - Zip Code:29429-5704
Practice Address - Country:US
Practice Address - Phone:814-282-7499
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty