Provider Demographics
NPI:1265650329
Name:JOURNEY PEDIATRIC REHABILITATION
Entity Type:Organization
Organization Name:JOURNEY PEDIATRIC REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KATHERINE
Authorized Official - Last Name:VILLARREAL
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:817-416-9797
Mailing Address - Street 1:2100 W NORTHWEST HWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-7808
Mailing Address - Country:US
Mailing Address - Phone:817-416-9797
Mailing Address - Fax:817-416-9714
Practice Address - Street 1:2100 W NORTHWEST HWY
Practice Address - Street 2:SUITE 202
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-7808
Practice Address - Country:US
Practice Address - Phone:817-416-9797
Practice Address - Fax:817-416-9714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105728225XP0200X
TX261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Not Answered261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities