Provider Demographics
NPI:1376156430
Name:PEDS TELE OT
Entity Type:Organization
Organization Name:PEDS TELE OT
Other - Org Name:CHILDREN'S THERAPY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:STOKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-926-6418
Mailing Address - Street 1:501 E 41ST ST 2R
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-1211
Mailing Address - Country:US
Mailing Address - Phone:443-926-6418
Mailing Address - Fax:
Practice Address - Street 1:501 E 41ST ST # 2R
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-1211
Practice Address - Country:US
Practice Address - Phone:443-926-6418
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-28
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD205184200Medicaid
MD998025300Medicaid