Healthcare Provider Details

I. General information

NPI: 1205101938
Provider Name (Legal Business Name): CANYON KIDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4833 RUGBY AVE STE 500
BETHESDA MD
20814-3910
US

IV. Provider business mailing address

4833 RUGBY AVE STE 500
BETHESDA MD
20814-3910
US

V. Phone/Fax

Practice location:
  • Phone: 301-523-0902
  • Fax: 240-244-0079
Mailing address:
  • Phone: 301-257-7387
  • Fax: 240-244-0079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL ROBERT HISCOCK
Title or Position: BUSINESS MANAGER
Credential:
Phone: 301-257-7387