Healthcare Provider Details

I. General information

NPI: 1437926789
Provider Name (Legal Business Name): FUNCTIONAL FOUNDATIONS PEDIATRIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2023
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3575 DONALD ST STE 300
EUGENE OR
97405-4700
US

IV. Provider business mailing address

3575 DONALD ST STE 300
EUGENE OR
97405-4700
US

V. Phone/Fax

Practice location:
  • Phone: 541-255-6400
  • Fax: 458-221-4205
Mailing address:
  • Phone: 541-255-6400
  • Fax: 458-221-4205

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 Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: SOPHIA PATEL
Title or Position: EXECUTIVE DIRECTOR
Credential: PT
Phone: 541-255-6400