Healthcare Provider Details

I. General information

NPI: 1922883453
Provider Name (Legal Business Name): KIDABLE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2023
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4335 BRAMBLETON AVE
ROANOKE VA
24018-3404
US

IV. Provider business mailing address

4335 BRAMBLETON AVE
ROANOKE VA
24018-3404
US

V. Phone/Fax

Practice location:
  • Phone: 540-315-3266
  • Fax:
Mailing address:
  • Phone: 540-315-3266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LAUREN VISTARAKULA
Title or Position: OWNER
Credential: OTD, OTR/L
Phone: 540-315-3210