MEDICARE: PEDIATRIC THERAPY SPECIALISTS OF SOUTH CENTRAL PA, LLC

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	225X00000X	Occupational Therapist	OC004139L	PA
2	252Y00000X	Early Intervention Provider Agency	OC004139L	PA

General Provider Information

NPI Number	:	1760738975
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC THERAPY SPECIALISTS OF SOUTH CENTRAL PA, LLC

Provider Business Mailing Address
First Line	:	2316 OCRACOKE ISLAND CT
Second Line	:
City	:	CHAMBERSBURG
State	:	PA
Zip	:	17202-7422
Country	:	US
Telephone Number	:	717-816-0742
Fax Number	:

Provider Business Practice Location Address
First Line	:	2316 OCRACOKE ISLAND CT
Second Line	:
City	:	CHAMBERSBURG
State	:	PA
Zip	:	17202-7422
Country	:	US
Telephone Number	:	717-816-0742
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ OCCUPATIONAL THERAPIST
Name	:	KRISTA MIRACLE
Credential	:	OTR/L
Telephone Number	:	717-816-0742

Provider Enumeration Date	:	07/25/2012
Last Update Date	:	07/27/2012

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