Provider Demographics
NPI:1447340732
Name:IMPACT THERAPY, LLC
Entity type:Organization
Organization Name:IMPACT THERAPY, LLC
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 1:1717 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:2006-10-15
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT10243174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891453200Medicaid