Healthcare Provider Details

I. General information

NPI: 1215697040
Provider Name (Legal Business Name): LITTLE LOON PEDIATRIC THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2021
Last Update Date: 02/18/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N KNIK ST
WASILLA AK
99654-7050
US

IV. Provider business mailing address

7362 W PARKS HWY # 496
WASILLA AK
99623-9300
US

V. Phone/Fax

Practice location:
  • Phone: 907-215-3105
  • Fax: 907-215-3385
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KAYLA HEAD
Title or Position: OWNER/SPEECH-LANGUAGE PATHOLOGIST
Credential: M.S., CCC-SLP
Phone: 360-608-2002