Healthcare Provider Details

I. General information

NPI: 1134562986
Provider Name (Legal Business Name): CHILD'S PLAY THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 04/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3304 SEVEN PINES DR
BELLEVILLE IL
62221-6638
US

IV. Provider business mailing address

3304 SEVEN PINES DR
BELLEVILLE IL
62221-6638
US

V. Phone/Fax

Practice location:
  • Phone: 618-978-0254
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINE TRODGLEN
Title or Position: OWNER
Credential:
Phone: 618-978-0254