Healthcare Provider Details

I. General information

NPI: 1083121792
Provider Name (Legal Business Name): LITTLE LIGHTS PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2018
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 CAPITOL WAY
BISMARCK ND
58501-2218
US

IV. Provider business mailing address

1615 CAPITOL WAY
BISMARCK ND
58501-2218
US

V. Phone/Fax

Practice location:
  • Phone: 701-751-0410
  • Fax:
Mailing address:
  • Phone: 701-751-0410
  • Fax: 855-834-5421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KRISANN MILLER
Title or Position: OWNER
Credential: OTR/L
Phone: 701-751-0410