=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215669619
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ISLAND PEDIATRIC THERAPY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2022
-----------------------------------------------------
Last Update Date | 06/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1744 SAM RITTENBERG BLVD
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29407-4935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-270-3412
-----------------------------------------------------
Fax | 843-627-4706
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 218
-----------------------------------------------------
City | EHRHARDT
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29081-0218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-270-3412
-----------------------------------------------------
Fax | 843-627-4706
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OCCUPATIONAL THERAPIST, OWNER
-----------------------------------------------------
Name | PATTI FRAZIER DANIEL
-----------------------------------------------------
Credential | OTR
-----------------------------------------------------
Telephone | 843-270-3412
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------