Provider Demographics
NPI:1104114412
Name:FOOTSTEPS AND HANDPRINTS PEDIATRIC THERAPY, LLC
Entity type:Organization
Organization Name:FOOTSTEPS AND HANDPRINTS PEDIATRIC THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:ONTIVEROS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:512-218-6955
Mailing Address - Street 1:3000 JOE DIMAGGIO BLVD SUITE 56
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665
Mailing Address - Country:US
Mailing Address - Phone:512-218-6955
Mailing Address - Fax:512-367-5965
Practice Address - Street 1:3000 JOE DIMAGGIO BLVD
Practice Address - Street 2:SUITE 56
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665
Practice Address - Country:US
Practice Address - Phone:512-218-6955
Practice Address - Fax:512-367-5965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-20
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11736282251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1980005-02Medicaid