Healthcare Provider Details

I. General information

NPI: 1750608022
Provider Name (Legal Business Name): MISSING PIECE THERAPY GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2010
Last Update Date: 04/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 UNIVERSITY PLZ
YOUNGSTOWN OH
44555-0001
US

IV. Provider business mailing address

406 ATWOOD CT
DOWNERS GROVE IL
60516-3054
US

V. Phone/Fax

Practice location:
  • Phone: 215-630-0123
  • Fax:
Mailing address:
  • Phone: 215-630-0123
  • 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 Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: DENISE M KURELKO
Title or Position: OWNER/MANAGER
Credential:
Phone: 215-630-0123