=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548985666
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIDDOS ABA THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2022
-----------------------------------------------------
Last Update Date | 10/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1011 N DEFIANCE ST
-----------------------------------------------------
City | OTTAWA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45875-1261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-615-1114
-----------------------------------------------------
Fax | 567-429-2041
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 540 E MAIN ST
-----------------------------------------------------
City | OTTAWA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45875-1950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-615-1114
-----------------------------------------------------
Fax | 567-429-2041
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COFOUNDER
-----------------------------------------------------
Name | KRISTEN CLOSSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 419-615-1114
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------