1558978932 NPI number — PHOENIX PEDIATRIC THERAPY SERVICES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558978932 NPI number — PHOENIX PEDIATRIC THERAPY SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX PEDIATRIC THERAPY SERVICES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558978932
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12806 SHOLTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UPPER MARLBORO
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20774-1715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-620-5688
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16201 TRADE ZONE AVE STE 106
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UPPER MARLBORO
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20774-8758
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-425-8605
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/29/2020

Additional Information

Authorized Official

Authorized Official Last Name:
PHOENIX
Authorized Official First Name:
TIFFANY
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
CEO/SPEECH-LANGUAGE PATHOLOGIST
Authorized Official Telephone Number:
240-425-8605

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2026 www.npivalidator.com