Healthcare Provider Details

I. General information

NPI: 1447376314
Provider Name (Legal Business Name): PEDIATRIC THERAPY PROFESSIONALS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 09/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 NE 20TH ST
PHILOMATH OR
97370
US

IV. Provider business mailing address

PO BOX 455
PHILOMATH OR
97370
US

V. Phone/Fax

Practice location:
  • Phone: 541-368-4313
  • Fax: 541-929-4967
Mailing address:
  • Phone: 541-368-4313
  • Fax: 541-929-4967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier247405
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: GERILYN JEAN AMAN
Title or Position: THERAPY COORDINATOR
Credential: OTRL
Phone: 541-368-4313