Healthcare Provider Details

I. General information

NPI: 1255879599
Provider Name (Legal Business Name): NORTHLAND PEDIATRIC PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2017
Last Update Date: 02/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6609 ROYAL ST STE 103
PLEASANT VALLEY MO
64068-8737
US

IV. Provider business mailing address

6609 ROYAL ST STE 103
PLEASANT VALLEY MO
64068-8737
US

V. Phone/Fax

Practice location:
  • Phone: 816-535-0011
  • Fax: 816-535-0377
Mailing address:
  • Phone: 816-535-0011
  • Fax: 816-535-0377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number2000167618
License Number StateMO

VIII. Authorized Official

Name: JENNIFER R HUYSER
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: PT
Phone: 816-535-0011