Healthcare Provider Details

I. General information

NPI: 1831362540
Provider Name (Legal Business Name): PEDIATRIC THERAPY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2008
Last Update Date: 04/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8050 SOQUEL DR SUITE A
APTOS CA
95003-3981
US

IV. Provider business mailing address

8050 SOQUEL DR SUITE A
APTOS CA
95003-3981
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT 9816
License Number StateCA

VIII. Authorized Official

Name: JULIANNE COLLIGAN
Title or Position: OCCUPATIONAL THERAPIST
Credential:
Phone: 831-331-9960