Healthcare Provider Details

I. General information

NPI: 1992236558
Provider Name (Legal Business Name): SOCIAL KIDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2017
Last Update Date: 03/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 MISTLETOE BLVD SUITE 3A
FORT WORTH TX
76110-1175
US

IV. Provider business mailing address

2120 MISTLETOE BLVD SUITE 3A
FORT WORTH TX
76110-1175
US

V. Phone/Fax

Practice location:
  • Phone: 817-821-8893
  • Fax:
Mailing address:
  • Phone: 817-821-8893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. WENDY PEDEN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 817-821-8893