Provider Demographics
NPI:1518490762
Name:TADPOLES PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:TADPOLES PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:IRACHETA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-302-9725
Mailing Address - Street 1:3901 PUEBLO TRL
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-2872
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8101 BOAT CLUB RD
Practice Address - Street 2:SUITE 160
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179-3630
Practice Address - Country:US
Practice Address - Phone:214-302-9725
Practice Address - Fax:214-935-2457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty