Provider Demographics
NPI:1730066960
Name:PEDIATRIC PLAY THERAPY
Entity type:Organization
Organization Name:PEDIATRIC PLAY THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SUE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:OT #1899
Authorized Official - Phone:408-218-4136
Mailing Address - Street 1:2109 OTOOLE AVE STE M
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95131-1338
Mailing Address - Country:US
Mailing Address - Phone:408-573-7720
Mailing Address - Fax:
Practice Address - Street 1:2109 OTOOLE AVE STE M
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95131-1338
Practice Address - Country:US
Practice Address - Phone:408-573-7720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-19
Last Update Date:2025-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No225XF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistFeeding, Eating & SwallowingGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty