Provider Demographics
NPI:1457384505
Name:CHILDREN'S THERAPY NETWORK, INC
Entity type:Organization
Organization Name:CHILDREN'S THERAPY NETWORK, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-428-4805
Mailing Address - Street 1:1604 S RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32132-3612
Mailing Address - Country:US
Mailing Address - Phone:386-428-4805
Mailing Address - Fax:866-457-5239
Practice Address - Street 1:1604 S RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32132-3612
Practice Address - Country:US
Practice Address - Phone:386-428-4805
Practice Address - Fax:866-457-5239
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDRENS THERAPY NETWORK, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-09
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Z00000X, 2251P0200X, 225200000X, 235Z00000X, 225X00000X
FLOT12846225XP0200X
FLPT14998225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL890529100Medicaid