=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437662814
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMPIRICAL PEDIATRIC THERAPY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2017
-----------------------------------------------------
Last Update Date | 11/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 413 FAIRMOUNT AVE # 1
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19123-2807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-908-7772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 702 N 3RD ST PMB 854
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-908-7772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | MR. JAISEN STANGO
-----------------------------------------------------
Credential | JD, MBA
-----------------------------------------------------
Telephone | 267-908-7772
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | BH002146
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OC010741
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------