Provider Demographics
NPI:1578951380
Name:FUNCTIONAL KIDS THERAPY CENTER LLC
Entity Type:Organization
Organization Name:FUNCTIONAL KIDS THERAPY CENTER LLC
Other - Org Name:FUNCTIONAL KIDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:DOBBERTIEN
Authorized Official - Suffix:
Authorized Official - Credentials:MSOTRL, LMT
Authorized Official - Phone:269-832-8224
Mailing Address - Street 1:777 GOGUAC ST W STE B2
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:49015-2097
Mailing Address - Country:US
Mailing Address - Phone:269-832-8224
Mailing Address - Fax:
Practice Address - Street 1:777 GOGUAC ST W STE B2
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MI
Practice Address - Zip Code:49015-2097
Practice Address - Country:US
Practice Address - Phone:269-832-8224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-31
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty