Provider Demographics
NPI:1447075759
Name:EARLY INTERVENTION THERAPY SERVICES, LLC.
Entity type:Organization
Organization Name:EARLY INTERVENTION THERAPY SERVICES, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, ITDS
Authorized Official - Prefix:
Authorized Official - First Name:KANDISE
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-663-1815
Mailing Address - Street 1:3531 CUNNINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-8228
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3531 CUNNINGHAM RD
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-8228
Practice Address - Country:US
Practice Address - Phone:912-663-1815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty