Provider Demographics
NPI:1619255015
Name:PEDIATRIC POTENTIALS THERAPY
Entity type:Organization
Organization Name:PEDIATRIC POTENTIALS THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SLP/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBSTER
Authorized Official - Suffix:
Authorized Official - Credentials:MACCC-SLP
Authorized Official - Phone:305-321-4343
Mailing Address - Street 1:9750 NW 33RD ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-4042
Mailing Address - Country:US
Mailing Address - Phone:305-321-4343
Mailing Address - Fax:954-827-0308
Practice Address - Street 1:9750 NW 33RD ST
Practice Address - Street 2:SUITE 209
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-4042
Practice Address - Country:US
Practice Address - Phone:305-321-4343
Practice Address - Fax:954-827-0308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-02
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2355S0801X, 224Z00000X, 225X00000X, 235Z00000X
FLSA 10752235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Multi-Specialty
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty