MEDICARE: SUCCESSFUL CHILD THERAPY 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	225XP0200X	Pediatric Occupational Therapist	1701909	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PHS	OTHER	KS	PREFERRED HEALTH SYSTEMS
2	115686	OTHER	KS	BCBS GROUP

General Provider Information

NPI Number	:	1790843175
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUCCESSFUL CHILD THERAPY LLC

Provider Business Mailing Address
First Line	:	1811 E BEAUMONT ST
Second Line	:
City	:	PARK CITY
State	:	KS
Zip	:	67219-2420
Country	:	US
Telephone Number	:	316-260-2251
Fax Number	:	316-744-3152

Provider Business Practice Location Address
First Line	:	1811 E BEAUMONT ST
Second Line	:
City	:	PARK CITY
State	:	KS
Zip	:	67219-2420
Country	:	US
Telephone Number	:	316-260-2251
Fax Number	:	316-744-3152

Authorized Official
Title or Position	:	OWNER
Name	:	MELINDA BETH SHELLENBERGER
Credential	:	OTR LICENSED
Telephone Number	:	316-260-2251

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	05/28/2008

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