Provider Demographics
NPI:1952660276
Name:ONLINE PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:ONLINE PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERI
Authorized Official - Middle Name:L
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:269-207-6501
Mailing Address - Street 1:16725 E C AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:MI
Mailing Address - Zip Code:49012-9332
Mailing Address - Country:US
Mailing Address - Phone:269-207-6501
Mailing Address - Fax:
Practice Address - Street 1:16725 E C AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:MI
Practice Address - Zip Code:49012-9332
Practice Address - Country:US
Practice Address - Phone:269-207-6501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-07
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501000917225100000X
MI5201000071225X00000X
CCC# 12120774235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty