Provider Demographics
NPI:1639579758
Name:SIERRA PEDIATRIC THERAPY CLINIC
Entity Type:Organization
Organization Name:SIERRA PEDIATRIC THERAPY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:N
Authorized Official - Last Name:CORN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MSPT, DPT
Authorized Official - Phone:916-791-2747
Mailing Address - Street 1:720 SUNRISE AVE
Mailing Address - Street 2:SUITE D110
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4516
Mailing Address - Country:US
Mailing Address - Phone:916-791-2747
Mailing Address - Fax:916-791-2189
Practice Address - Street 1:720 SUNRISE AVE
Practice Address - Street 2:SUITE D110
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4516
Practice Address - Country:US
Practice Address - Phone:916-791-2747
Practice Address - Fax:916-791-2189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-26
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT6842251P0200X
CAOT7936225XF0002X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225XF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistFeeding, Eating & SwallowingGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty