=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053069500
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOVE MOUNTAINS PEDIATRIC THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2022
-----------------------------------------------------
Last Update Date | 03/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2931 HIGHWAY 52
-----------------------------------------------------
City | PAYETTE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83661-5530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-250-7060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2931 HIGHWAY 52
-----------------------------------------------------
City | PAYETTE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83661-5530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-250-7060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | STEPHANIE ROBINSON
-----------------------------------------------------
Credential | MS CCC-SLP
-----------------------------------------------------
Telephone | 208-250-7060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------