Healthcare Provider Details

I. General information

NPI: 1770189748
Provider Name (Legal Business Name): KEYSTONE PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2020
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8595 BEECHMONT AVE STE 202
CINCINNATI OH
45255-5415
US

IV. Provider business mailing address

8595 BEECHMONT AVE STE 202
CINCINNATI OH
45255-5415
US

V. Phone/Fax

Practice location:
  • Phone: 513-278-7006
  • Fax: 513-440-7926
Mailing address:
  • Phone: 513-278-7006
  • Fax: 513-440-7926

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: AIREAL ISHOLA
Title or Position: OCCUPATIONAL THERAPIST
Credential: OTR/L
Phone: 513-278-7006