Healthcare Provider Details

I. General information

NPI: 1922876218
Provider Name (Legal Business Name): SPECKLED FROG PEDIATRIC THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2023
Last Update Date: 12/15/2023
Certification Date: 12/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

643 MAIN ST
BRAWLEY CA
92227-2547
US

IV. Provider business mailing address

11003 EXPOSITION BLVD
LOS ANGELES CA
90064-3139
US

V. Phone/Fax

Practice location:
  • Phone: 760-235-9047
  • Fax:
Mailing address:
  • Phone: 760-235-9047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. SARAH ELIZABETH O'BRIEN
Title or Position: PRESIDENT
Credential:
Phone: 760-235-9047