Provider Demographics
NPI:1629315411
Name:PREMIER PEDIATRIC THERAPY SOURCE, INC.
Entity Type:Organization
Organization Name:PREMIER PEDIATRIC THERAPY SOURCE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:OTD
Authorized Official - Phone:703-879-2479
Mailing Address - Street 1:2776 S ARLINGTON MILL DR # 534
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22206-3402
Mailing Address - Country:US
Mailing Address - Phone:703-879-2479
Mailing Address - Fax:703-879-2803
Practice Address - Street 1:2776 S ARLINGTON MILL DR # 534
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22206-3402
Practice Address - Country:US
Practice Address - Phone:703-879-2479
Practice Address - Fax:703-879-2803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119005367225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty