Healthcare Provider Details

I. General information

NPI: 1366899171
Provider Name (Legal Business Name): NORTH VALLEY PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2016
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1831 W ROSE GARDEN LN STE 4
PHOENIX AZ
85027-2725
US

IV. Provider business mailing address

1831 W ROSE GARDEN LN STE 4
PHOENIX AZ
85027-2725
US

V. Phone/Fax

Practice location:
  • Phone: 602-808-9912
  • Fax: 602-875-0385
Mailing address:
  • Phone: 602-808-9912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAXSON MYERS
Title or Position: CEO
Credential:
Phone: 602-609-3777