Healthcare Provider Details

I. General information

NPI: 1760178776
Provider Name (Legal Business Name): GROW PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 07/26/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

488 E 11TH AVE STE LL2
EUGENE OR
97401-3601
US

IV. Provider business mailing address

488 E 11TH AVE STE LL2
EUGENE OR
97401-3601
US

V. Phone/Fax

Practice location:
  • Phone: 541-505-8180
  • Fax:
Mailing address:
  • Phone: 541-359-1009
  • Fax: 541-359-1039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: RYLIE A STOKES
Title or Position: MEMBER
Credential:
Phone: 406-431-9623