Healthcare Provider Details

I. General information

NPI: 1477886232
Provider Name (Legal Business Name): CHILDRENS INTENSIVE THERAPY NORTHWEST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2009
Last Update Date: 07/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7203 SE RAYMOND ST
PORTLAND OR
97206-4323
US

IV. Provider business mailing address

12948 SE WINSTON RD
DAMASCUS OR
97089-7606
US

V. Phone/Fax

Practice location:
  • Phone: 503-895-1320
  • Fax: 503-296-2319
Mailing address:
  • Phone: 971-570-5043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number5680
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number4970
License Number StateOR

VIII. Authorized Official

Name: MR. DARREN DAVID BRAULT
Title or Position: OWNER
Credential:
Phone: 971-570-5043