Provider Demographics
NPI:1801770201
Name:STREETER, DEDRICA (PTA)
Entity type:Individual
Prefix:
First Name:DEDRICA
Middle Name:
Last Name:STREETER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 QUAIL ROOST DR
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:FL
Mailing Address - Zip Code:32352-9037
Mailing Address - Country:US
Mailing Address - Phone:850-841-9310
Mailing Address - Fax:
Practice Address - Street 1:2301 LUCIEN WAY STE 325
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7020
Practice Address - Country:US
Practice Address - Phone:800-774-7785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-31
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA32950225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant