Provider Demographics
NPI:1952075574
Name:CHILD THERAPY LAB LLC
Entity Type:Organization
Organization Name:CHILD THERAPY LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:RONIQUA
Authorized Official - Middle Name:TESHAE
Authorized Official - Last Name:ZIMMERMANN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:317-662-4403
Mailing Address - Street 1:53174 FLOWING STREAM CT
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-9034
Mailing Address - Country:US
Mailing Address - Phone:317-662-4403
Mailing Address - Fax:317-900-1896
Practice Address - Street 1:53174 FLOWING STREAM CT
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-9034
Practice Address - Country:US
Practice Address - Phone:317-662-4403
Practice Address - Fax:317-900-1896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty