Healthcare Provider Details

I. General information

NPI: 1457384505
Provider Name (Legal Business Name): CHILDREN'S THERAPY NETWORK, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 09/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1604 S RIDGEWOOD AVE
EDGEWATER FL
32132-3612
US

IV. Provider business mailing address

1604 S RIDGEWOOD AVE
EDGEWATER FL
32132-3612
US

V. Phone/Fax

Practice location:
  • Phone: 386-428-4805
  • Fax: 866-457-5239
Mailing address:
  • Phone: 386-428-4805
  • Fax: 866-457-5239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT12846
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT14998
License Number StateFL
# 7
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: GINA JOHNSON
Title or Position: PRESIDENT
Credential:
Phone: 386-428-4805