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General NPI Number Information
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NPI Number | 1023487105
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Entity Type | Organization
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Legal Business Name | JOURNEY PEDIATRIC THERAPY
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Dates
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Enumeration Date | 09/18/2015
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Last Update Date | 06/01/2022
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Provider Practice Location Address
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Address Line | 1009 HIGHWAY 2 STE C
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City | SANDPOINT
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State | ID
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Zip | 83864-2713
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Country | US
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Telephone | 208-627-8615
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Fax | 208-441-2641
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Provider Business Mailing Address
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Address Line | PO BOX 2476
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City | SANDPOINT
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State | ID
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Zip | 83864-0914
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OCCUPATIONAL THERAPIST AND OWNER
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Name | MARESA BLACK
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Credential | OTR/L
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Telephone | 208-627-8615
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QR0400X
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Taxonomy Name | Rehabilitation Clinic/Center
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License Number | OT-1405
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License Number State | ID
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