Healthcare Provider Details

I. General information

NPI: 1699976233
Provider Name (Legal Business Name): MAIN LINE PEDIATRIC THERAPY CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 08/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 ROSCOMMON RD
BRYN MAWR PA
19010-1845
US

IV. Provider business mailing address

PO BOX 139
GLADWYNE PA
19035-0139
US

V. Phone/Fax

Practice location:
  • Phone: 610-527-7715
  • Fax: 610-527-7716
Mailing address:
  • Phone: 610-527-7714
  • Fax: 610-527-7716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License NumberPT003148L
License Number StatePA

VIII. Authorized Official

Name: MRS. ABBE BERNSTEIN AVART
Title or Position: CO-OWNER, CO-DIRECTOR
Credential: MSPT
Phone: 610-527-7714