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General NPI Number Information
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NPI Number | 1194125617
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Entity Type | Organization
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Legal Business Name | IDAHO PEDIATRIC THERAPY CLINIC PLLC
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Dates
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Enumeration Date | 09/03/2014
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Last Update Date | 07/09/2019
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Provider Practice Location Address
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Address Line | 3080 E GENTRY WAY STE 180
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City | MERIDIAN
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State | ID
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Zip | 83642-3544
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Country | US
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Telephone | 208-939-3334
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Fax | 208-939-1122
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Provider Business Mailing Address
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Address Line | 3080 E GENTRY WAY STE 180
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City | MERIDIAN
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State | ID
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Zip | 83642-3544
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Country | US
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Telephone | 89-393-3342
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Fax | 208-939-1122
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | JENNIFER LONGORIA
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Credential |
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Telephone | 208-939-3334
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | OT-928
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SLP-2249
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT-1450
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License Number State | ID
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