Healthcare Provider Details

I. General information

NPI: 1700474889
Provider Name (Legal Business Name): SENECA PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2021
Last Update Date: 01/05/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2837 BRIARWOOD DR
TIFFIN OH
44883-9704
US

IV. Provider business mailing address

2837 BRIARWOOD DR
TIFFIN OH
44883-9704
US

V. Phone/Fax

Practice location:
  • Phone: 561-847-1108
  • Fax:
Mailing address:
  • Phone: 561-847-1108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. AMANDA LEANN WIDMAN
Title or Position: SPEECH LANGUAGE PATHOLOGIST
Credential: M.S., CCC-SLP
Phone: 561-847-1108