Healthcare Provider Details

I. General information

NPI: 1861617722
Provider Name (Legal Business Name): PEDIATRIC THERAPY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 08/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2577 SAMARITAN DR SUITE 715
SAN JOSE CA
95124-4100
US

IV. Provider business mailing address

2577 SAMARITAN DR SUITE 715
SAN JOSE CA
95124-4100
US

V. Phone/Fax

Practice location:
  • Phone: 408-358-8330
  • Fax: 408-358-8334
Mailing address:
  • Phone: 408-358-8330
  • Fax: 408-904-7178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MS. CHRISTINE MORRIS BACON
Title or Position: DIRECTOR OF SERVICES , OWNER
Credential: M.A. CCC SLP
Phone: 408-358-8330