Provider Demographics
NPI:1518390616
Name:BLAST OFF CHILDREN'S THERAPY SERVICES, INC.
Entity Type:Organization
Organization Name:BLAST OFF CHILDREN'S THERAPY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LUANN
Authorized Official - Middle Name:H
Authorized Official - Last Name:LOWER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:858-866-8133
Mailing Address - Street 1:9520 PADGETT ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4445
Mailing Address - Country:US
Mailing Address - Phone:858-866-8133
Mailing Address - Fax:858-999-2002
Practice Address - Street 1:9520 PADGETT ST
Practice Address - Street 2:SUITE 104
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4445
Practice Address - Country:US
Practice Address - Phone:858-866-8133
Practice Address - Fax:858-999-2002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13795261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA13795OtherSLP LICENSE