Healthcare Provider Details

I. General information

NPI: 1205022373
Provider Name (Legal Business Name): SWING FOR THE STARS PEDIATRIC THERAPY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2007
Last Update Date: 06/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 PILLSBURY ST STE 404
CONCORD NH
03301-3523
US

IV. Provider business mailing address

2 PILLSBURY ST STE 404
CONCORD NH
03301-3523
US

V. Phone/Fax

Practice location:
  • Phone: 603-228-7827
  • Fax: 603-228-7828
Mailing address:
  • Phone: 603-228-7827
  • Fax: 603-228-7828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1126
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number1712
License Number StateNH
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3719
License Number StateNH
# 4
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number3719
License Number StateNH
# 5
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1712
License Number StateNH

VIII. Authorized Official

Name: MRS. JODELLE L HEATH
Title or Position: EXECUTIVE DIRECTOR
Credential: MS OTR/L
Phone: 603-228-7827