Basic Information
| Provider Information | |||||||||
| NPI: | 1619554680 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CORTICA DEVELOPMENTAL THERAPIES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10201 WATERIDGE CIR STE 450 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921215800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8582168837 | ||||||||
| FaxNumber: | 8883830040 | ||||||||
| Practice Location | |||||||||
| Address1: | 5085 W PARK BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750932000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8582168837 | ||||||||
| FaxNumber: | 8883830040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2021 | ||||||||
| LastUpdateDate: | 04/04/2022 | ||||||||
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| AuthorizedOfficialLastName: | GOH-HATTANGADI | ||||||||
| AuthorizedOfficialFirstName: | SUZANNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8582168837 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0008X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neurodevelopmental Disabilities | 261QD1600X | N | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.