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
State | License ID | Taxonomies |
---|---|---|
224Z00000X, 2251P0200X, 225200000X, 225X00000X, 235Z00000X | ||
FL | PT14998 | 225100000X |
FL | OT12846 | 225XP0200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
No | 224Z00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | Group - Multi-Specialty | |
No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
No | 2251P0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | Group - Multi-Specialty |
No | 225200000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | Group - Multi-Specialty | |
No | 225XP0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | Group - Multi-Specialty |
No | 235Z00000X | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 890529100 | Medicaid |