Healthcare Provider Details

I. General information

NPI: 1679155295
Provider Name (Legal Business Name): FUNCTIONAL PLAYGROUND THERAPIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2021
Last Update Date: 11/22/2022
Certification Date: 11/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9577 OSUNA RD NE STE B
ALBUQUERQUE NM
87111-2286
US

IV. Provider business mailing address

8205 PORTALES ST NE
ALBUQUERQUE NM
87109-4955
US

V. Phone/Fax

Practice location:
  • Phone: 505-263-0583
  • Fax: 505-317-2532
Mailing address:
  • Phone: 505-263-0583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: TALIA HOUSER
Title or Position: OWNER
Credential: OT
Phone: 505-263-0583