Healthcare Provider Details

I. General information

NPI: 1902177025
Provider Name (Legal Business Name): CENTRA PEDIATRIC THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2012
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3002 DOW AVE STE 114
TUSTIN CA
92780-7247
US

IV. Provider business mailing address

3002 DOW AVE #114
TUSTIN CA
92780-7236
US

V. Phone/Fax

Practice location:
  • Phone: 714-731-4668
  • Fax: 714-464-4668
Mailing address:
  • Phone: 714-731-4668
  • Fax: 714-464-4668

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 Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MR. WAYNE BRIAN CENTRA
Title or Position: OWNER/OCCUPATIONAL THERAPIST
Credential: OT
Phone: 714-731-4668