MEDICARE: PREMIER PEDIATRIC THERAPY SOURCE, 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	225XP0200X	Pediatric Occupational Therapist	0119005367	VA

General Provider Information

NPI Number	:	1629315411
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER PEDIATRIC THERAPY SOURCE, INC.

Provider Business Mailing Address
First Line	:	2776 S ARLINGTON MILL DR # 534
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22206-3402
Country	:	US
Telephone Number	:	703-879-2479
Fax Number	:	703-879-2803

Provider Business Practice Location Address
First Line	:	2776 S ARLINGTON MILL DR # 534
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22206-3402
Country	:	US
Telephone Number	:	703-879-2479
Fax Number	:	703-879-2803

Authorized Official
Title or Position	:	PRESIDENT & CEO
Name	:	DR. DEBBIE ALLEN
Credential	:	OTD
Telephone Number	:	703-879-2479

Provider Enumeration Date	:	01/14/2013
Last Update Date	:	01/14/2013

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