Provider Demographics
NPI:1578191524
Name:ISHINE PEDIATRIC THERAPY CLINIC
Entity Type:Organization
Organization Name:ISHINE PEDIATRIC THERAPY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:TARWATER
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:830-431-0115
Mailing Address - Street 1:616 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-1622
Mailing Address - Country:US
Mailing Address - Phone:830-431-0115
Mailing Address - Fax:
Practice Address - Street 1:616 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-1622
Practice Address - Country:US
Practice Address - Phone:830-431-0115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-27
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty