Healthcare Provider Details

I. General information

NPI: 1972603454
Provider Name (Legal Business Name): EARTH ANGELS THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2006
Last Update Date: 08/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10101 N 91ST AVE #112
PEORIA AZ
85345-8335
US

IV. Provider business mailing address

10101 N 91ST AVE #112
PEORIA AZ
85345-8335
US

V. Phone/Fax

Practice location:
  • Phone: 623-521-5387
  • Fax: 866-896-0786
Mailing address:
  • Phone: 623-521-5387
  • Fax: 866-896-0786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number0311
License Number StateAZ

VIII. Authorized Official

Name: MS. NANCY ANN PALATNIK
Title or Position: OWNER
Credential: OTR/L
Phone: 623-521-5387