Healthcare Provider Details

I. General information

NPI: 1790022762
Provider Name (Legal Business Name): PEDIATRIC NEUROMOTOR CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2013
Last Update Date: 01/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 19TH ST S ROOM 115
BIRMINGHAM AL
35205-3703
US

IV. Provider business mailing address

1720 2ND AVE S CH 19 307
BIRMINGHAM AL
35294-2041
US

V. Phone/Fax

Practice location:
  • Phone: 205-975-0466
  • Fax: 205-975-2380
Mailing address:
  • Phone: 205-975-0466
  • Fax: 205-975-2380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MARY REBEKAH TRUCKS
Title or Position: DIRECTOR
Credential: M.S., OTR/L
Phone: 205-975-0466