Healthcare Provider Details

I. General information

NPI: 1083759021
Provider Name (Legal Business Name): FUNCTIONAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6613 BRAYTON DR SUITE A
ANCHORAGE AK
99507-2127
US

IV. Provider business mailing address

PO BOX 113394
ANCHORAGE AK
99511-3394
US

V. Phone/Fax

Practice location:
  • Phone: 907-334-9002
  • Fax: 907-334-9320
Mailing address:
  • Phone: 907-334-9002
  • Fax: 907-334-9320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number StateAK

VIII. Authorized Official

Name: JERRY PASOL
Title or Position: OTR
Credential: OTR
Phone: 907-334-9002