Healthcare Provider Details

I. General information

NPI: 1730066960
Provider Name (Legal Business Name): PEDIATRIC PLAY THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2025
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2109 OTOOLE AVE STE M
SAN JOSE CA
95131-1338
US

IV. Provider business mailing address

2109 OTOOLE AVE STE M
SAN JOSE CA
95131-1338
US

V. Phone/Fax

Practice location:
  • Phone: 408-573-7720
  • Fax:
Mailing address:
  • Phone: 408-573-7720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MS. SUE M HENRY
Title or Position: PRESIDENT
Credential: OT #1899
Phone: 408-218-4136