Basic Information
| Provider Information | |||||||||
| NPI: | 1316421456 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPECIAL KIDS INNOVATION PROGRAM INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 AVENUE B SE | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338803037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632941429 | ||||||||
| FaxNumber: | 8632980299 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 AVENUE B SE | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338803037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632941429 | ||||||||
| FaxNumber: | 8632980299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2018 | ||||||||
| LastUpdateDate: | 09/24/2018 | ||||||||
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| AuthorizedOfficialLastName: | COMKOWYCZ | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8632941429 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MS CCC-SLP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 2251P0200X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | 225200000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225XP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 235Z00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.