=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598348807
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SENDERO PEDIATRIC THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2021
-----------------------------------------------------
Last Update Date | 05/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34 N WASHINGTON ST
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73401-7013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-395-5008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1164 LUMBERMAN RD
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73401-8886
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-395-5008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / SLP
-----------------------------------------------------
Name | MOLLY PATIRICIA CANTARELLA
-----------------------------------------------------
Credential | M.S., CCC/SLP
-----------------------------------------------------
Telephone | 940-395-5008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------