Healthcare Provider Details

I. General information

NPI: 1902568074
Provider Name (Legal Business Name): CHILD LED THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2021
Last Update Date: 10/06/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8108 THISTLE CT
SAN DIEGO CA
92120-1620
US

IV. Provider business mailing address

8108 THISTLE CT
SAN DIEGO CA
92120-1620
US

V. Phone/Fax

Practice location:
  • Phone: 858-752-4675
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MELISSA SUBLETT
Title or Position: PRESIDENT/BCBA
Credential:
Phone: 858-752-4675