Healthcare Provider Details

I. General information

NPI: 1780014480
Provider Name (Legal Business Name): KIDSTLC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2013
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 S ROGERS RD
OLATHE KS
66062-1704
US

IV. Provider business mailing address

480 S ROGERS RD
OLATHE KS
66062-1706
US

V. Phone/Fax

Practice location:
  • Phone: 913-324-3823
  • Fax: 913-780-3387
Mailing address:
  • Phone: 913-324-3636
  • Fax: 913-780-3387

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 Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MARY THOMAS
Title or Position: CFO
Credential:
Phone: 913-324-3681