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General NPI Number Information
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NPI Number | 1366638975
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Entity Type | Organization
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Legal Business Name | KIDMOTION BRENDA CHILSTROM PEDIATRIC OCCUPATIONAL THERAPIST LLC
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Dates
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Enumeration Date | 09/18/2007
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Last Update Date | 09/18/2007
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Provider Practice Location Address
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Address Line | 102 PEBBLE SHORES DRIVE #202
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City | NAPLES
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State | FL
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Zip | 34110
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Country | US
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Telephone | 239-595-7018
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Fax | 239-597-3287
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Provider Business Mailing Address
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Address Line | PO BOX 111896
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City | NAPLES
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State | FL
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Zip | 34108
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Country | US
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Telephone | 239-595-7018
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Fax | 239-597-3287
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Authorized Official
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Title or Position | OCCUPATIONAL THERAPIST
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Name | BRENDA CHILSTROM
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Credential | OTRL
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Telephone | 239-595-7018
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | OT9691
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License Number State | FL
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