Healthcare Provider Details

I. General information

NPI: 1619658499
Provider Name (Legal Business Name): KIDS SPEECH, PHYSICAL, AND OCCUPATIONAL THERAPY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2023
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12448 SW 127TH AVE FL 2
MIAMI FL
33186-6596
US

IV. Provider business mailing address

12448 SW 127TH AVE FL 2
MIAMI FL
33186-6596
US

V. Phone/Fax

Practice location:
  • Phone: 305-255-5980
  • Fax:
Mailing address:
  • Phone: 305-255-5980
  • 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 Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANNIE BOUCHEREAU
Title or Position: PRESIDENT
Credential:
Phone: 954-445-3064