MEDICARE: DEVELOPMENTAL PHYSICAL THERAPY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251P0200X	Pediatric Physical Therapist

General Provider Information

NPI Number	:	1295383941
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEVELOPMENTAL PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	101 S KRAEMER BLVD STE 125
Second Line	:
City	:	PLACENTIA
State	:	CA
Zip	:	92870-6100
Country	:	US
Telephone Number	:	714-624-2315
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 S KRAEMER BLVD STE 125
Second Line	:
City	:	PLACENTIA
State	:	CA
Zip	:	92870-6100
Country	:	US
Telephone Number	:	714-624-2315
Fax Number	:

Authorized Official
Title or Position	:	MPT/OWNER
Name	:	KIMBERLY CLARK
Credential	:	PT
Telephone Number	:	714-624-2315

Provider Enumeration Date	:	08/27/2019
Last Update Date	:	08/27/2019

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Directions to “DEVELOPMENTAL PHYSICAL THERAPY ” Practice Location

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