Provider Demographics
NPI:1578041398
Name:CHILDREN'S SPOT 4 THERAPY, LLC
Entity Type:Organization
Organization Name:CHILDREN'S SPOT 4 THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLICKENER
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:254-781-3447
Mailing Address - Street 1:1121 WESTWAY DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-5151
Mailing Address - Country:US
Mailing Address - Phone:361-523-1049
Mailing Address - Fax:
Practice Address - Street 1:2300 E RANCIER AVE STE 106
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-3450
Practice Address - Country:US
Practice Address - Phone:254-781-3447
Practice Address - Fax:254-227-6163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX204183201Medicaid