Healthcare Provider Details

I. General information

NPI: 1184938003
Provider Name (Legal Business Name): BAYSIDE CHILDREN'S THERAPY NETWORK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2010
Last Update Date: 09/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6688 MAIN ST
GLOUCESTER VA
23061-5194
US

IV. Provider business mailing address

PO BOX 130
GLOUCESTER VA
23061-0130
US

V. Phone/Fax

Practice location:
  • Phone: 804-210-1555
  • Fax:
Mailing address:
  • Phone: 804-210-1555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number2305000705
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number0119004244
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202003940
License Number StateVA

VIII. Authorized Official

Name: LISA MCCANN
Title or Position: PRESIDENT, OT
Credential: MA, OTR
Phone: 804-210-1555