MEDICARE: LITTLE RED WAGON PEDIATRIC 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	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1831569052
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LITTLE RED WAGON PEDIATRIC THERAPY, LLC

Provider Business Mailing Address
First Line	:	4524 BOAT CLUB RD STE 180
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76135-7025
Country	:	US
Telephone Number	:	817-764-3825
Fax Number	:

Provider Business Practice Location Address
First Line	:	4524 BOAT CLUB RD STE 180
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76135-7025
Country	:	US
Telephone Number	:	817-764-3825
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	GABRIELA GOODWIN
Credential	:
Telephone Number	:	817-764-3825

Provider Enumeration Date	:	09/30/2015
Last Update Date	:	03/26/2024

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Directions to “LITTLE RED WAGON PEDIATRIC THERAPY, LLC ” Practice Location

Language	Start Address	Practice Location

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