Provider Demographics
NPI:1679057194
Name:SOCAL THERAPLAY
Entity Type:Organization
Organization Name:SOCAL THERAPLAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HEIDENREICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-267-3361
Mailing Address - Street 1:29595 PUJOL ST APT 1104
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-6764
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29595 PUJOL ST APT 1104
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-6764
Practice Address - Country:US
Practice Address - Phone:951-225-9065
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency