Provider Demographics
NPI:1477632719
Name:FOX, IVORY TEODORO (PT)
Entity type:Individual
Prefix:MRS
First Name:IVORY
Middle Name:TEODORO
Last Name:FOX
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 1:12220 TOWNE LAKE DR STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913-8021
Mailing Address - Country:US
Mailing Address - Phone:239-433-6700
Mailing Address - Fax:
Practice Address - Street 1:12220 TOWNE LAKE DR STE 1
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33913-8021
Practice Address - Country:US
Practice Address - Phone:239-433-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT33437225100000X
222Q00000X
IN05003234A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL222Q00000XMedicaid
IN225100000XMedicaid
FL225100000X-PTMedicaid