Healthcare Provider Details

I. General information

NPI: 1760579015
Provider Name (Legal Business Name): INNOVATIVE THERAPY 4 KIDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2333 STATE ST SUITE 201
CARLSBAD CA
92008-1691
US

IV. Provider business mailing address

2333 STATE ST SUITE 201
CARLSBAD CA
92008-1691
US

V. Phone/Fax

Practice location:
  • Phone: 760-434-3912
  • Fax: 760-434-3871
Mailing address:
  • Phone: 760-434-3912
  • Fax: 760-434-3871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberSP9589
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberSP9589
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberSP9589
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License NumberSP9589
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP9589
License Number StateCA

VIII. Authorized Official

Name: MRS. LAURA JANE WALLS
Title or Position: ORAL MOTOR SPECIALIST DIRECTOR
Credential: MS CCCSLP
Phone: 760-434-3912