Healthcare Provider Details

I. General information

NPI: 1124640131
Provider Name (Legal Business Name): MOUNTAIN KIDZ THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 05/13/2020
Certification Date: 05/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2861 W HARE DR
FLAGSTAFF AZ
86001-2584
US

IV. Provider business mailing address

2861 W HARE DR
FLAGSTAFF AZ
86001-2584
US

V. Phone/Fax

Practice location:
  • Phone: 520-275-2935
  • Fax:
Mailing address:
  • Phone: 520-275-2935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: ERIN MARTINEZ
Title or Position: PT
Credential: PT, DPT
Phone: 520-275-2935