Healthcare Provider Details

I. General information

NPI: 1982477030
Provider Name (Legal Business Name): PINE PEAK THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2023
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 HILLIGOSS BLVD SE
FOSSTON MN
56542-1541
US

IV. Provider business mailing address

PO BOX 300
FOSSTON MN
56542-0300
US

V. Phone/Fax

Practice location:
  • Phone: 218-435-1210
  • Fax: 218-435-1175
Mailing address:
  • Phone: 218-435-1210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MALLORY ALICE VIG
Title or Position: OCCUPATIONAL THERAPIST
Credential: OTR/L
Phone: 218-435-1210