Healthcare Provider Details

I. General information

NPI: 1639579758
Provider Name (Legal Business Name): SIERRA PEDIATRIC THERAPY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2014
Last Update Date: 11/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 SUNRISE AVE SUITE D110
ROSEVILLE CA
95661-4516
US

IV. Provider business mailing address

720 SUNRISE AVE SUITE D110
ROSEVILLE CA
95661-4516
US

V. Phone/Fax

Practice location:
  • Phone: 916-791-2747
  • Fax: 916-791-2189
Mailing address:
  • Phone: 916-791-2747
  • Fax: 916-791-2189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT684
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License NumberOT7936
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT7936
License Number StateCA

VIII. Authorized Official

Name: DR. KRISTINE N. CORN
Title or Position: OWNER
Credential: PT, MSPT, DPT
Phone: 916-791-2747