Provider Demographics
NPI:1326424334
Name:RIDGEWOOD PEDIATRIC THERAPY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:RIDGEWOOD PEDIATRIC THERAPY ASSOCIATES, LLC
Other - Org Name:FUNTASTIC GYM
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTOS-MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:201-251-9446
Mailing Address - Street 1:611 NORTH MAPLE AVENUE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:HO HO KUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07423
Mailing Address - Country:US
Mailing Address - Phone:201-251-9446
Mailing Address - Fax:201-251-0147
Practice Address - Street 1:611 NORTH MAPLE AVENUE
Practice Address - Street 2:SUITE 7
Practice Address - City:HO HO KUS
Practice Address - State:NJ
Practice Address - Zip Code:07423
Practice Address - Country:US
Practice Address - Phone:201-251-9446
Practice Address - Fax:201-251-0147
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIDGEWOOD PEDIATRIC THERAPY ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-08-03
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00153900225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty