MEDICARE: EMPIRICAL PEDIATRIC THERAPY, INC.

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	103K00000X	Behavior Analyst	BH002146	PA
2	225X00000X	Occupational Therapist	OC010741	PA

General Provider Information

NPI Number	:	1437662814
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMPIRICAL PEDIATRIC THERAPY, INC.

Provider Business Mailing Address
First Line	:	702 N 3RD ST PMB 854
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19123
Country	:	US
Telephone Number	:	267-908-7772
Fax Number	:

Provider Business Practice Location Address
First Line	:	413 FAIRMOUNT AVE # 1
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19123-2807
Country	:	US
Telephone Number	:	267-908-7772
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. JAISEN STANGO
Credential	:	JD, MBA
Telephone Number	:	267-908-7772

Provider Enumeration Date	:	11/08/2017
Last Update Date	:	11/08/2017

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