Healthcare Provider Details

I. General information

NPI: 1508264623
Provider Name (Legal Business Name): THERAPY PLACE 4 KIDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2014
Last Update Date: 02/16/2021
Certification Date: 02/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1932 14TH ST
SANTA MONICA CA
90404-4605
US

IV. Provider business mailing address

1932 14TH ST
SANTA MONICA CA
90404-4605
US

V. Phone/Fax

Practice location:
  • Phone: 949-683-0884
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical 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 Number12467
License Number StateCA

VIII. Authorized Official

Name: KIMBERLY GARDENER
Title or Position: OWNER/MANAGER
Credential: OTD, OTR/L, SWC, CAS
Phone: 310-344-2276