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General NPI Number Information
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NPI Number | 1760891824
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Entity Type | Organization
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Legal Business Name | EPIC PEDIATRIC THERAPY
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Dates
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Enumeration Date | 08/03/2014
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Last Update Date | 08/03/2014
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Provider Practice Location Address
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Address Line | 6155 SIENNA TRL APT 612
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City | BEAUMONT
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State | TX
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Zip | 77708-4357
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Country | US
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Telephone | 786-797-0382
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Fax |
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Provider Business Mailing Address
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Address Line | 6155 SIENNA TRL APT 612
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City | BEAUMONT
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State | TX
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Zip | 77708-4357
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Country | US
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Telephone | 786-797-0382
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Fax |
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Authorized Official
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Title or Position | COTA
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Name | KIMBERLY GORDON
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Credential |
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Telephone | 786-797-0382
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 385HR2060X
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Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
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License Number | 212133
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License Number State | TX
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