Provider Demographics
NPI:1083000764
Name:CHILD CARE THERAPY, LLC
Entity Type:Organization
Organization Name:CHILD CARE THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSSONI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-993-8028
Mailing Address - Street 1:1756 HALIFAX ST
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262-1388
Mailing Address - Country:US
Mailing Address - Phone:469-993-8028
Mailing Address - Fax:844-269-9518
Practice Address - Street 1:1756 HALIFAX ST
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:TX
Practice Address - Zip Code:76262
Practice Address - Country:US
Practice Address - Phone:310-975-5043
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-09
Last Update Date:2018-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3625592Medicaid