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General NPI Number Information
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NPI Number | 1467225946
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Entity Type | Organization
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Legal Business Name | BROOKSIDE PEDIATRIC THERAPY LLC
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Dates
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Enumeration Date | 11/06/2023
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Last Update Date | 10/07/2024
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Provider Practice Location Address
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Address Line | 39650 ORCHARD HILL PL
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City | NOVI
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State | MI
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Zip | 48375-5392
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Country | US
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Telephone | 248-747-4263
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Fax |
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Provider Business Mailing Address
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Address Line | 39650 ORCHARD HILL PL
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City | NOVI
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State | MI
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Zip | 48375-5392
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Country | US
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Telephone | 248-266-1188
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | YASSER MANSOUR
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Credential |
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Telephone | 313-207-4645
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225XP0019X
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Taxonomy Name | Physical Rehabilitation Occupational Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2355S0801X
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Taxonomy Name | Speech-Language Assistant
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 106E00000X
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Taxonomy Name | Assistant Behavior Analyst
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License Number |
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License Number State |
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Taxonomy #9
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number |
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License Number State |
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Taxonomy #10
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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Taxonomy #11
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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Taxonomy #12
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number |
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License Number State |
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Taxonomy #13
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Taxonomy Code | 225XM0800X
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Taxonomy Name | Mental Health Occupational Therapist
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License Number |
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License Number State |
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Taxonomy #14
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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