MEDICARE: KIDTASTIC CONSULTING SERVICES, 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	252Y00000X	Early Intervention Provider Agency	210765081	NY

General Provider Information

NPI Number	:	1730329459
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDTASTIC CONSULTING SERVICES, INC.

Provider Business Mailing Address
First Line	:	62 BIRCH ST
Second Line	:
City	:	LAKE GROVE
State	:	NY
Zip	:	11755-2743
Country	:	US
Telephone Number	:	631-553-7952
Fax Number	:

Provider Business Practice Location Address
First Line	:	62 BIRCH ST
Second Line	:
City	:	LAKE GROVE
State	:	NY
Zip	:	11755-2743
Country	:	US
Telephone Number	:	631-553-7952
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. DAWNMARIE GARRETT
Credential	:	MSED
Telephone Number	:	631-553-7952

Provider Enumeration Date	:	02/21/2009
Last Update Date	:	02/21/2009

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