=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104141019
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FANTASTIC KIDS THERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2010
-----------------------------------------------------
Last Update Date | 04/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1519 E BUSTAMANTE ST STE G
-----------------------------------------------------
City | LAREDO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78041-5305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-208-8707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 GODORNIZ
-----------------------------------------------------
City | RIO GRANDE CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78582-6656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-844-1031
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | AIDE GARZA
-----------------------------------------------------
Credential | LOTR
-----------------------------------------------------
Telephone | 956-488-8100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number | 110165
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------