Provider Demographics
NPI:1265697882
Name:PEDIATRIC THERAPEUTICS-PT,OT,SLP&CSW,PLLC
Entity type:Organization
Organization Name:PEDIATRIC THERAPEUTICS-PT,OT,SLP&CSW,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARYBETH
Authorized Official - Middle Name:
Authorized Official - Last Name:DEJOHN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:716-362-0020
Mailing Address - Street 1:90 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-4106
Mailing Address - Country:US
Mailing Address - Phone:716-362-0020
Mailing Address - Fax:716-362-0022
Practice Address - Street 1:90 PEARL ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-4106
Practice Address - Country:US
Practice Address - Phone:716-362-0020
Practice Address - Fax:716-362-0022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-23
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4752568252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency