Healthcare Provider Details

I. General information

NPI: 1053178079
Provider Name (Legal Business Name): NORTHERN PEDIATRIC THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2024
Last Update Date: 03/15/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19080 RIDGE VIEW LN
LAKE ANN MI
49650-9411
US

IV. Provider business mailing address

PO BOX 5817
TRAVERSE CITY MI
49696-5817
US

V. Phone/Fax

Practice location:
  • Phone: 616-706-2916
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MEGAN DOWNER
Title or Position: SPEECH LANGUAGE PATHOLOGY
Credential: SLP
Phone: 231-577-9421