Healthcare Provider Details

I. General information

NPI: 1083779649
Provider Name (Legal Business Name): ABC PEDIATRIC THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 02/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3440 S OLEANDER DR
CHANDLER AZ
85248-3655
US

IV. Provider business mailing address

3440 S OLEANDER DR
CHANDLER AZ
85248-3655
US

V. Phone/Fax

Practice location:
  • Phone: 480-726-0000
  • Fax: 480-726-9999
Mailing address:
  • Phone: 480-726-0000
  • Fax: 480-726-9999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: ALYCIA VIRGA
Title or Position: OFFICE MANAGER
Credential:
Phone: 480-726-0000