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General NPI Number Information
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NPI Number | 1952660276
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Entity Type | Organization
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Legal Business Name | ONLINE PEDIATRIC THERAPY
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Dates
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Enumeration Date | 05/07/2012
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Last Update Date | 05/07/2012
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Provider Practice Location Address
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Address Line | 16725 E C AVE
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City | AUGUSTA
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State | MI
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Zip | 49012-9332
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Country | US
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Telephone | 269-207-6501
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Fax |
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Provider Business Mailing Address
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Address Line | 16725 E C AVE
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City | AUGUSTA
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State | MI
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Zip | 49012-9332
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Country | US
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Telephone | 269-207-6501
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Fax |
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Authorized Official
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Title or Position | PARTNER
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Name | MRS. TERI L ALLEN
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Credential | OTR/L
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Telephone | 269-207-6501
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 5501000917
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | CCC# 12120774
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License Number State |
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Taxonomy #3
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 5201000071
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License Number State | MI
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