Provider Demographics
NPI:1366638975
Name:KIDMOTION BRENDA CHILSTROM PEDIATRIC OCCUPATIONAL THERAPIST LLC
Entity Type:Organization
Organization Name:KIDMOTION BRENDA CHILSTROM PEDIATRIC OCCUPATIONAL THERAPIST LLC
Other - Org Name:KIDMOTION
Other - Org Type:Other Name
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHILSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:OTRL
Authorized Official - Phone:239-595-7018
Mailing Address - Street 1:PO BOX 111896
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108
Mailing Address - Country:US
Mailing Address - Phone:239-595-7018
Mailing Address - Fax:239-597-3287
Practice Address - Street 1:102 PEBBLE SHORES DRIVE
Practice Address - Street 2:#202
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110
Practice Address - Country:US
Practice Address - Phone:239-595-7018
Practice Address - Fax:239-597-3287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT9691225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty