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General NPI Number Information
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NPI Number | 1639441371
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Entity Type | Organization
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Legal Business Name | MONKEYS AND MOONS PEDIATRIC THERAPY, LLC
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Dates
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Enumeration Date | 01/26/2012
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Last Update Date | 01/26/2012
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Provider Practice Location Address
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Address Line | 4238 FRONT ST
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City | WINNSBORO
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State | LA
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Zip | 71295-4139
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Country | US
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Telephone | 318-348-2500
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Fax |
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Provider Business Mailing Address
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Address Line | 1343 HIGHWAY 618
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City | WINNSBORO
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State | LA
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Zip | 71295-4629
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Country | US
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Telephone | 318-348-2500
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. MOLLY MCLEMORE BLAYLOCK
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Credential | LCOTA
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Telephone | 318-348-2500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | OTA.200086
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License Number State | LA
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