Healthcare Provider Details

I. General information

NPI: 1902520828
Provider Name (Legal Business Name): OUR VILLAGE THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2022
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7316 RIDGE GROVE CT
RALEIGH NC
27615-5908
US

IV. Provider business mailing address

7316 RIDGE GROVE CT
RALEIGH NC
27615-5908
US

V. Phone/Fax

Practice location:
  • Phone: 919-417-7259
  • Fax:
Mailing address:
  • Phone: 919-417-7259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER L WALTHER
Title or Position: EXECUTIVE DIRECTOR
Credential: MS, OTR/L
Phone: 919-417-7259