Provider Demographics
NPI:1003200254
Name:BRIGHT HORIZONS PEDIATRIC THERAPY LLC
Entity Type:Organization
Organization Name:BRIGHT HORIZONS PEDIATRIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLERTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-541-7938
Mailing Address - Street 1:411 COUNTRY DOWNS DR
Mailing Address - Street 2:
Mailing Address - City:LAKE SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-4310
Mailing Address - Country:US
Mailing Address - Phone:314-541-7938
Mailing Address - Fax:
Practice Address - Street 1:411 COUNTRY DOWNS DR
Practice Address - Street 2:
Practice Address - City:LAKE SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-4310
Practice Address - Country:US
Practice Address - Phone:314-541-7938
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-25
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010025352225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty