Healthcare Provider Details

I. General information

NPI: 1366609166
Provider Name (Legal Business Name): CHILDREN'S THERAPY CONNECTION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 11/11/2022
Certification Date: 11/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7209 N SHADELAND AVE
INDIANAPOLIS IN
46250-2021
US

IV. Provider business mailing address

7209 N SHADELAND AVE
INDIANAPOLIS IN
46250-2021
US

V. Phone/Fax

Practice location:
  • Phone: 317-288-7606
  • Fax: 317-288-7607
Mailing address:
  • Phone: 317-288-7606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JASON BERTY
Title or Position: PRESIDENT
Credential: PT, CSCS
Phone: 317-288-7606