Healthcare Provider Details

I. General information

NPI: 1316391840
Provider Name (Legal Business Name): PEDIATRIC THERAPY PLAYGROUND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2016
Last Update Date: 04/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 VISTA DE COLINAS DR SE
RIO RANCHO NM
87124-3070
US

IV. Provider business mailing address

3649 CAPE CENTER DR
FAYETTEVILLE NC
28304-4457
US

V. Phone/Fax

Practice location:
  • Phone: 910-484-1711
  • Fax: 919-869-1685
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: ROBERTO DIOSDADO
Title or Position: CEO
Credential:
Phone: 910-484-1711