Provider Demographics
NPI:1104141019
Name:FANTASTIC KIDS THERAPY PLLC
Entity type:Organization
Organization Name:FANTASTIC KIDS THERAPY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:AIDE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARZA
Authorized Official - Suffix:
Authorized Official - Credentials:LOTR
Authorized Official - Phone:956-488-8100
Mailing Address - Street 1:500 GODORNIZ
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78582-6656
Mailing Address - Country:US
Mailing Address - Phone:956-844-1031
Mailing Address - Fax:
Practice Address - Street 1:1519 E BUSTAMANTE ST STE G
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-5305
Practice Address - Country:US
Practice Address - Phone:956-208-8707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-02
Last Update Date:2010-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110165225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty