Healthcare Provider Details

I. General information

NPI: 1285751636
Provider Name (Legal Business Name): FOURT THERAPY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

849 MENLO AVE
MENLO PARK CA
94025-4728
US

IV. Provider business mailing address

849 MENLO AVE
MENLO PARK CA
94025-4728
US

V. Phone/Fax

Practice location:
  • Phone: 650-323-0805
  • Fax: 650-323-5262
Mailing address:
  • Phone: 650-323-0805
  • Fax: 650-323-5262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number1779
License Number StateCA

VIII. Authorized Official

Name: MS. BARBARA FOURT
Title or Position: DIRECTOR
Credential: MA, OTR
Phone: 650-321-4020