Provider Demographics
NPI:1902954662
Name:CEREBRAL PALSY OF NORTHEAST FLORIDA
Entity Type:Organization
Organization Name:CEREBRAL PALSY OF NORTHEAST FLORIDA
Other - Org Name:THERAPY SOURCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-396-1462
Mailing Address - Street 1:10000 GATE PKWY N
Mailing Address - Street 2:#1913
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-8280
Mailing Address - Country:US
Mailing Address - Phone:904-998-9806
Mailing Address - Fax:
Practice Address - Street 1:3271 TIGER HOLE RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5859
Practice Address - Country:US
Practice Address - Phone:904-730-6066
Practice Address - Fax:904-443-6264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 9707174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty