Provider Demographics
NPI:1740938448
Name:KICKSTART PEDIATRIC THERAPY, LLC
Entity type:Organization
Organization Name:KICKSTART PEDIATRIC THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:K
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:MS, OTR/L
Authorized Official - Phone:315-408-1337
Mailing Address - Street 1:185 CRESCENT ST APT 412
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-3498
Mailing Address - Country:US
Mailing Address - Phone:315-408-1337
Mailing Address - Fax:
Practice Address - Street 1:185 CRESCENT ST APT 412
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-3498
Practice Address - Country:US
Practice Address - Phone:315-408-1337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KICKSTART PEDIATRIC THERAPY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-03-13
Last Update Date:2022-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty