Healthcare Provider Details

I. General information

NPI: 1043769615
Provider Name (Legal Business Name): CHILDREN'S THERAPY CONCEPTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2016
Last Update Date: 09/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24030 INDIAN TOWN RD
COURTLAND VA
23837-2371
US

IV. Provider business mailing address

24030 INDIAN TOWN RD
COURTLAND VA
23837-2371
US

V. Phone/Fax

Practice location:
  • Phone: 757-812-3288
  • Fax:
Mailing address:
  • Phone: 757-812-3288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number2305204928
License Number StateVA

VIII. Authorized Official

Name: KIM MALLON
Title or Position: PHYSICAL THERAPIST
Credential: DPT
Phone: 757-812-3288