Provider Demographics
NPI:1790843175
Name:SUCCESSFUL CHILD THERAPY LLC
Entity Type:Organization
Organization Name:SUCCESSFUL CHILD THERAPY LLC
Other - Org Name:MELINDA BETH SHELLENBERGER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:SHELLENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:OTR LICENSED
Authorized Official - Phone:316-260-2251
Mailing Address - Street 1:1811 E BEAUMONT ST
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67219-2420
Mailing Address - Country:US
Mailing Address - Phone:316-260-2251
Mailing Address - Fax:316-744-3152
Practice Address - Street 1:1811 E BEAUMONT ST
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:KS
Practice Address - Zip Code:67219-2420
Practice Address - Country:US
Practice Address - Phone:316-260-2251
Practice Address - Fax:316-744-3152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1701909225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSPHSOtherPREFERRED HEALTH SYSTEMS
KS115686OtherBCBS GROUP