Healthcare Provider Details

I. General information

NPI: 1477831782
Provider Name (Legal Business Name): MAGICAL KIDS THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 08/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3507 LOOP 20 STE 1
LAREDO TX
78043-4743
US

IV. Provider business mailing address

3507 LOOP 20 STE 1
LAREDO TX
78043-4743
US

V. Phone/Fax

Practice location:
  • Phone: 956-753-6355
  • Fax:
Mailing address:
  • Phone: 956-753-6355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number101359
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number100590
License Number StateTX

VIII. Authorized Official

Name: JUAN E. PEREZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 956-753-6355