Healthcare Provider Details

I. General information

NPI: 1962024943
Provider Name (Legal Business Name): ROOTS PEDIATRIC THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2020
Last Update Date: 05/12/2020
Certification Date: 05/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5976 KINGSFORD AVE
PARK CITY UT
84098-6315
US

IV. Provider business mailing address

5976 KINGSFORD AVE
PARK CITY UT
84098-6315
US

V. Phone/Fax

Practice location:
  • Phone: 907-744-3978
  • Fax:
Mailing address:
  • Phone: 907-744-3978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: ROBYN THOMPSON
Title or Position: OWNER
Credential: PHD, OTR/L
Phone: 907-744-3978