Provider Demographics
NPI:1053624155
Name:KIDDLY WINKS THERAPEUTICS, LLC
Entity type:Organization
Organization Name:KIDDLY WINKS THERAPEUTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARISA
Authorized Official - Middle Name:G
Authorized Official - Last Name:PURSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-587-6772
Mailing Address - Street 1:3140 LAUREL LN
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-4108
Mailing Address - Country:US
Mailing Address - Phone:573-587-6772
Mailing Address - Fax:
Practice Address - Street 1:875 N KINGSHIGHWAY ST
Practice Address - Street 2:SUITE B
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-4315
Practice Address - Country:US
Practice Address - Phone:573-587-6772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-17
Last Update Date:2010-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002014370225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty