Provider Demographics
NPI:1427306356
Name:FUNCTIONAL KIDS THERAPY LLC
Entity type:Organization
Organization Name:FUNCTIONAL KIDS THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGRM
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:MHS, OTR/L
Authorized Official - Phone:904-838-0800
Mailing Address - Street 1:1232 HARBOUR TOWN DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-2562
Mailing Address - Country:US
Mailing Address - Phone:904-838-0800
Mailing Address - Fax:904-291-2426
Practice Address - Street 1:1232 HARBOUR TOWN DR
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-2562
Practice Address - Country:US
Practice Address - Phone:904-838-0800
Practice Address - Fax:904-291-2426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-27
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT9446225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty