Healthcare Provider Details

I. General information

NPI: 1053754911
Provider Name (Legal Business Name): PLAY TO GROW DEVELOPMENTAL THERAPY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2013
Last Update Date: 04/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18959 SW 84TH AVE
TUALATIN OR
97062-9477
US

IV. Provider business mailing address

18959 SW 84TH AVE
TUALATIN OR
97062-9477
US

V. Phone/Fax

Practice location:
  • Phone: 500-356-3543
  • Fax: 503-563-5281
Mailing address:
  • Phone: 500-356-3543
  • Fax: 503-563-5281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number606012
License Number StateOR

VIII. Authorized Official

Name: DEBORAH LEE FERGUSON
Title or Position: OCCUPATIONAL THERAPIST DIRECTOR
Credential: OTR
Phone: 503-563-5439