Healthcare Provider Details

I. General information

NPI: 1518687656
Provider Name (Legal Business Name): PLAYOLOGY PEDIATRIC THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 E PICKWICK DR
SYRACUSE IN
46567-1713
US

IV. Provider business mailing address

3305 GRAPE RD STE 3
MISHAWAKA IN
46545-2714
US

V. Phone/Fax

Practice location:
  • Phone: 574-524-0036
  • Fax:
Mailing address:
  • Phone: 574-217-7423
  • Fax: 574-213-5319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: HAVILAH CHAMPOUX
Title or Position: OWNER/OCCUPATIONAL THERAPIST
Credential: MS, OTR
Phone: 574-524-0036