{
"Npi": {
"NPI": "1184019184",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "KIDSPACE THERAPY, LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "2145 TIBBETTS DR STE A",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "LONGVIEW",
"MailingAddressStateName": "WA",
"MailingAddressPostalCode": "98632-4211",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "360-560-1972",
"MailingAddressFaxNumber": "360-703-3452",
"FirstLinePracticeLocationAddress": "2145 TIBBETTS DR STE A",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "LONGVIEW",
"PracticeLocationAddressStateName": "WA",
"PracticeLocationAddressPostalCode": "98632-4211",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "360-560-1972",
"PracticeLocationAddressFaxNumber": "360-703-3452",
"EnumerationDate": "04/06/2015",
"LastUpdateDate": "07/15/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "WOLFF",
"AuthorizedOfficialFirstName": "LESLIE",
"AuthorizedOfficialMiddleName": "KAY",
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "OTR/L",
"AuthorizedOfficialTelephoneNumber": "360-560-1972",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "261Q00000X",
"TaxonomyName": "Clinic/Center",
"LicenseNumber": "OT00001294",
"LicenseNumberStateCode": "WA",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "261QD1600X",
"TaxonomyName": "Developmental Disabilities Clinic/Center",
"LicenseNumber": "603464065",
"LicenseNumberStateCode": "WA",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}