=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558488361
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC THERAPY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2007
-----------------------------------------------------
Last Update Date | 05/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1940 BONITA DR. - UPSTAIRS
-----------------------------------------------------
City | APTOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-684-1804
-----------------------------------------------------
Fax | 831-684-1826
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1940 BONITA DR. - UPSTAIRS
-----------------------------------------------------
City | APTOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-684-1804
-----------------------------------------------------
Fax | 831-684-1826
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF SERVICES- OWNER
-----------------------------------------------------
Name | KERI LYNN ALLEN
-----------------------------------------------------
Credential | MOT, OTR/L
-----------------------------------------------------
Telephone | 831-684-1804
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number | OT6062
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number | OT7552
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SP11200
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SP12998
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SP5343
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT29813
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number | OT398
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number | OT2656
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------