=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831362540
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC THERAPY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2008
-----------------------------------------------------
Last Update Date | 04/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8050 SOQUEL DR SUITE A
-----------------------------------------------------
City | APTOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95003-3981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-684-1804
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8050 SOQUEL DR SUITE A
-----------------------------------------------------
City | APTOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95003-3981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-684-1804
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OCCUPATIONAL THERAPIST
-----------------------------------------------------
Name | JULIANNE COLLIGAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 831-331-9960
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number | OT 9816
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------