Healthcare Provider Details

I. General information

NPI: 1376677914
Provider Name (Legal Business Name): NORTHLAND-RURAL THERAPY ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2915 NORTH 4TH STREET
FLAGSTAFF AZ
86004
US

IV. Provider business mailing address

2915 NORTH 4TH STREET
FLAGSTAFF AZ
86004
US

V. Phone/Fax

Practice location:
  • Phone: 928-779-1679
  • Fax: 928-779-2822
Mailing address:
  • Phone: 928-779-1679
  • Fax: 928-779-2822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: THOMAS COSNER
Title or Position: PHYSICAL THERAPIST, OWNER, DIRECTOR
Credential: PT
Phone: 928-779-1679