Provider Demographics
NPI:1790464204
Name:ENVISION PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:ENVISION PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:734-883-4950
Mailing Address - Street 1:26033 GETTY DR UNIT 421
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-0977
Mailing Address - Country:US
Mailing Address - Phone:734-883-4950
Mailing Address - Fax:
Practice Address - Street 1:26033 GETTY DR UNIT 421
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-0977
Practice Address - Country:US
Practice Address - Phone:734-883-4950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty