Provider Demographics
NPI:1053450742
Name:CHILDREN'S THERAPY CTR, INC
Entity Type:Organization
Organization Name:CHILDREN'S THERAPY CTR, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:OTRL
Authorized Official - Phone:651-994-9644
Mailing Address - Street 1:4058 DEERWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-1889
Mailing Address - Country:US
Mailing Address - Phone:651-994-9644
Mailing Address - Fax:651-994-8962
Practice Address - Street 1:14635 PENNOCK AVE
Practice Address - Street 2:#300
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-6430
Practice Address - Country:US
Practice Address - Phone:952-997-2823
Practice Address - Fax:952-997-6931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2251P0200X, 225XP0200X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN962S7CHOtherBCBS SP
MN521091043137OtherPREFERRED ONE
MN043755700Medicaid
MN7610098OtherAETNA
MN960S0CHOtherBCBS OT
MN105647OtherHEALTHPARTNERS
MN965S5CHOtherBCBS PT