{
"Npi": {
"NPI": "1104141019",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "FANTASTIC KIDS THERAPY PLLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "500 GODORNIZ",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "RIO GRANDE CITY",
"MailingAddressStateName": "TX",
"MailingAddressPostalCode": "78582-6656",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "956-844-1031",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "1519 E BUSTAMANTE ST STE G",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "LAREDO",
"PracticeLocationAddressStateName": "TX",
"PracticeLocationAddressPostalCode": "78041-5305",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "956-208-8707",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "04/02/2010",
"LastUpdateDate": "04/02/2010",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "GARZA",
"AuthorizedOfficialFirstName": "AIDE",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "MANAGING MEMBER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "LOTR",
"AuthorizedOfficialTelephoneNumber": "956-488-8100",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "225XP0200X",
"TaxonomyName": "Pediatric Occupational Therapist",
"LicenseNumber": "110165",
"LicenseNumberStateCode": "TX",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}