Provider Demographics
NPI:1699032094
Name:PEDIATRIC PLAYHOUSE
Entity Type:Organization
Organization Name:PEDIATRIC PLAYHOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:SWIDEREK
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:630-291-0470
Mailing Address - Street 1:5726 N PASEO OTONO
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85750-1252
Mailing Address - Country:US
Mailing Address - Phone:630-291-0470
Mailing Address - Fax:520-615-9607
Practice Address - Street 1:5726 N PASEO OTONO
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85750-1252
Practice Address - Country:US
Practice Address - Phone:630-291-0470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-23
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X, 225X00000X, 225XN1300X, 225XP0019X, 225XP0200X
AZ3878252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitationGroup - Single Specialty
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical RehabilitationGroup - Single Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Single Specialty