Provider Demographics
NPI:1790022762
Name:PEDIATRIC NEUROMOTOR CLINIC
Entity Type:Organization
Organization Name:PEDIATRIC NEUROMOTOR CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY REBEKAH
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUCKS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, OTR/L
Authorized Official - Phone:205-975-0466
Mailing Address - Street 1:1720 2ND AVE S
Mailing Address - Street 2:CH 19 307
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35294-2041
Mailing Address - Country:US
Mailing Address - Phone:205-975-0466
Mailing Address - Fax:205-975-2380
Practice Address - Street 1:933 19TH ST S
Practice Address - Street 2:ROOM 115
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-3703
Practice Address - Country:US
Practice Address - Phone:205-975-0466
Practice Address - Fax:205-975-2380
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPARKS CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty