Healthcare Provider Details

I. General information

NPI: 1295339620
Provider Name (Legal Business Name): FOUNDATIONS PEDIATRIC THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2020
Last Update Date: 04/02/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 E 1ST ST
MIDDLETON ID
83644
US

IV. Provider business mailing address

11536 W PRISTINEBROOK DR
STAR ID
83669-5784
US

V. Phone/Fax

Practice location:
  • Phone: 208-654-6161
  • Fax: 208-473-7320
Mailing address:
  • Phone: 208-654-6161
  • Fax: 208-473-7320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: TIFFANY POLLOCK
Title or Position: OWNER / THERAPIST
Credential: OTR/L
Phone: 208-651-6161