Healthcare Provider Details

I. General information

NPI: 1790189025
Provider Name (Legal Business Name): OPTIMAL THERAPY FOR KIDS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2014
Last Update Date: 10/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 ROCK CREEK DR S
SALEM OR
97306-2222
US

IV. Provider business mailing address

1145 ROCK CREEK DR S
SALEM OR
97306-2222
US

V. Phone/Fax

Practice location:
  • Phone: 503-453-6335
  • Fax:
Mailing address:
  • Phone: 503-453-6335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number4469
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number306415
License Number StateOR

VIII. Authorized Official

Name: SASCHA GERVAIS
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: PT
Phone: 503-453-6335