Provider Demographics
NPI:1396398830
Name:CHILDHOOD COACH,LLC
Entity Type:Organization
Organization Name:CHILDHOOD COACH,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARCELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HORN-MANDIOLA
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:407-364-9070
Mailing Address - Street 1:309 FOX SQUIRREL LN
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-4904
Mailing Address - Country:US
Mailing Address - Phone:407-364-9070
Mailing Address - Fax:
Practice Address - Street 1:309 FOX SQUIRREL LN
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-4904
Practice Address - Country:US
Practice Address - Phone:407-364-9070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty