Provider Demographics
NPI:1902024912
Name:PEDIATRIC THERAPY & ACTIVITY CENTER
Entity Type:Organization
Organization Name:PEDIATRIC THERAPY & ACTIVITY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKENNA
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:940-497-3003
Mailing Address - Street 1:1406 N. CORINTH ST
Mailing Address - Street 2:SUITE 405
Mailing Address - City:CORINTH
Mailing Address - State:TX
Mailing Address - Zip Code:76208
Mailing Address - Country:US
Mailing Address - Phone:940-497-3003
Mailing Address - Fax:940-497-9153
Practice Address - Street 1:2606 BRANDI LANE
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:TX
Practice Address - Zip Code:76208
Practice Address - Country:US
Practice Address - Phone:940-497-3003
Practice Address - Fax:940-497-9153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103499225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty