Basic Information
| Provider Information | |||||||||
| NPI: | 1598892739 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THERAPY UNLIMITED-CHILDREN'S THERAPY CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JUMPSTART THERAPY & FITNESS NETWORK | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O BOX 425 | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067950425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609453012 | ||||||||
| FaxNumber: | 8609459854 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OAKVILLE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067791999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609453012 | ||||||||
| FaxNumber: | 8609459854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 11/18/2011 | ||||||||
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| AuthorizedOfficialLastName: | RISIGO-WICKLINE | ||||||||
| AuthorizedOfficialFirstName: | CATHERINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8609453012 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CT | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 251C00000X | Y | Agencies | Day Training, Developmentally Disabled Services |
ID Information
| ID | Type | State | Issuer | Description | 004186111 | 05 | CT | MEDICAID |