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General NPI Number Information
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NPI Number | 1427306356
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Entity Type | Organization
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Legal Business Name | FUNCTIONAL KIDS THERAPY LLC
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Dates
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Enumeration Date | 08/27/2012
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Last Update Date | 05/19/2014
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Provider Practice Location Address
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Address Line | 1232 HARBOUR TOWN DR
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City | ORANGE PARK
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State | FL
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Zip | 32065-2562
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Country | US
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Telephone | 904-838-0800
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Fax | 904-291-2426
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Provider Business Mailing Address
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Address Line | 1232 HARBOUR TOWN DR
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City | ORANGE PARK
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State | FL
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Zip | 32065-2562
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Country | US
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Telephone | 904-838-0800
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Fax | 904-291-2426
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Authorized Official
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Title or Position | MGRM
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Name | JOAN T WARREN
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Credential | MHS, OTR/L
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Telephone | 904-838-0800
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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 | OT9446
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License Number State | FL
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