Provider Demographics
NPI:1619554680
Name:CORTICA DEVELOPMENTAL THERAPIES PA
Entity Type:Organization
Organization Name:CORTICA DEVELOPMENTAL THERAPIES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOH-HATTANGADI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-216-8837
Mailing Address - Street 1:6160 CORNERSTONE CT E STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-3724
Mailing Address - Country:US
Mailing Address - Phone:858-216-8837
Mailing Address - Fax:888-383-0040
Practice Address - Street 1:5085 W PARK BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-2000
Practice Address - Country:US
Practice Address - Phone:972-665-8484
Practice Address - Fax:469-409-4557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-25
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental DisabilitiesGroup - Multi-Specialty
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities