Healthcare Provider Details

I. General information

NPI: 1336506823
Provider Name (Legal Business Name): PRISM PEDIATRIC THERAPY ASSOCIATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2016
Last Update Date: 03/01/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7409 NE HAZEL DELL AVE
VANCOUVER WA
98665-8310
US

IV. Provider business mailing address

1940 S BONITO WAY STE 190
MERIDIAN ID
83642-5618
US

V. Phone/Fax

Practice location:
  • Phone: 208-287-9420
  • Fax:
Mailing address:
  • Phone: 208-287-9420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT-00003758
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT-60135582
License Number StateWA

VIII. Authorized Official

Name: JENNIFER RAINEY-YATES
Title or Position: OWNER
Credential: PT, DPT
Phone: 360-597-4048