Healthcare Provider Details

I. General information

NPI: 1568641520
Provider Name (Legal Business Name): PEDIATRIC PLAY THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2007
Last Update Date: 04/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 BERN CT STE 140
SAN JOSE CA
95112-1242
US

IV. Provider business mailing address

911 BERN CT STE 140
SAN JOSE CA
95112-1242
US

V. Phone/Fax

Practice location:
  • Phone: 408-573-7720
  • Fax: 844-789-4011
Mailing address:
  • Phone: 408-573-7720
  • Fax: 844-789-4011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number2269
License Number StateCA

VIII. Authorized Official

Name: MRS. LETICIA VARGAS
Title or Position: CO-DIRECTOR
Credential: OTR/L
Phone: 408-573-7720