Healthcare Provider Details

I. General information

NPI: 1629701438
Provider Name (Legal Business Name): BUILDING GREAT KIDS THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2022
Last Update Date: 07/08/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1738 EAGAN RD
MADISON WI
53704-3736
US

IV. Provider business mailing address

N7169 E PLAZA DR
BEAVER DAM WI
53916-9403
US

V. Phone/Fax

Practice location:
  • Phone: 218-590-6530
  • Fax:
Mailing address:
  • Phone: 920-887-7545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. KEITH ALAN RITSCHE
Title or Position: OCCUPATIONAL THERAPIST/DIRECTOR
Credential: OTR/L
Phone: 218-590-6530