Healthcare Provider Details

I. General information

NPI: 1558488361
Provider Name (Legal Business Name): PEDIATRIC THERAPY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2007
Last Update Date: 05/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 BONITA DR. - UPSTAIRS
APTOS CA
95003
US

IV. Provider business mailing address

1940 BONITA DR. - UPSTAIRS
APTOS CA
95003
US

V. Phone/Fax

Practice location:
  • Phone: 831-684-1804
  • Fax: 831-684-1826
Mailing address:
  • Phone: 831-684-1804
  • Fax: 831-684-1826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT6062
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT7552
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP11200
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP12998
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP5343
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT29813
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT398
License Number StateCA
# 8
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT2656
License Number StateCA

VIII. Authorized Official

Name: KERI LYNN ALLEN
Title or Position: DIRECTOR OF SERVICES- OWNER
Credential: MOT, OTR/L
Phone: 831-684-1804